HIV Stigma and Its Relation to Mental, Physical and Social Health Among Black Women Living with HIV/AIDS

Innovations to Address Unmet Behavioral Health Needs in National Ending the HIV Epidemic Priority Jurisdictions

ABSTRACT

People who have behavioral health disorders are disproportionately represented among people with HIV and those likely to be diagnosed with HIV. Despite repeated calls for the past decade for the integration of behavioral health into the HIV Care Continuum, findings from priority jurisdictions show these efforts lag. We present 5 examples of efforts to integrate behavioral health services into the HIV Care Continuum, across regions and populations in Ending the HIV Epidemic priority regions. Across diverse settings, care provision-screening, assessment, referrals, and treatments-remains insufficient. Consistent, ongoing actions are needed to address the compounded consequences of the HIV and behavioral health synergistic epidemics, or syndemic. The studies in this article involved local communities, provider groups, and people with lived experience of trauma, serious mental illness, neuropsychological disorder, substance use disorder, and HIV. These example studies reveal significant unmet needs for behavioral health care and/or HIV prevention and treatment in these priority communities. A common finding among these examples was that the success of interventions hinges on the extent to which interventions are tailored to local contexts and the specific needs of historically underserved populations, including Black women, the socioeconomically disadvantaged, LGBTQIA+ individuals, and people with serious mental illness and/or substance use disorders. We suggest recommendations for how Ending the HIV Epidemic efforts can be optimized to adapt and implement integrated HIV and behavioral health care to advance national goals.

Intersectional HIV Stigma Among Black Women: Regional Differences and Implications From the Black Women First Initiative

Objectives. To explore intersectional stigma and sociodemographic characteristics, with consideration of US regional differences, among Black women with HIV enrolled in the Black Women First (BWF) initiative. Methods. In this prospective, nonrandomized study, participants' stigma scale responses and sociodemographic data were collected between May 2021 and August 2023. Participants participated in bundled interventions tailored to Black women's needs and local contexts during this time. Repeated measure models, adjusted for site clustering, were conducted with consideration of regional differences. Results. There were significant sociodemographic and baseline stigma differences between Black women residing in the US South and other regions. By the 12-month follow-up timepoint, because of bundled interventions, stigma significantly reduced among Black women, especially women in the South and transgender women. Conclusions. Bundled interventions with stigma-reduction approaches that address intersectional stigma and consider geography may be an effective way to reduce and eliminate stigma for Black women with HIV. Public Health Implications. BWF aligns with the National HIV/AIDS Strategy (2022-2025), promoting the development and expansion of culturally sensitive, evidence-informed interventions to improve Black women's health outcomes. (Am J Public Health. 2025;115(S1):S75-S84. https://doi.org/10.2105/AJPH.2025.308037).

" I Look in the Mirror and Say ' You Know What, There Is Hope for You '"-An Interpretative Qualitative Study of Current and Future Well-Being in Black African Women Older Than 50 Years With HIV in the United Kingdom

ABSTRACT

Effective antiretroviral treatment means that people with HIV are living for longer. This includes Black African women, who represent a large proportion of people aging with HIV in the United Kingdom. Despite this, the impact of living and aging with HIV on the well-being of Black African women aging with HIV has not been investigated. Interpretative phenomenological analysis of interviews with eight Black African women ages 50 years and older living with HIV developed six superordinate themes. Findings demonstrated how experiences of HIV-related stigma negatively affected social, occupational, and psychological well-being. Perspectives on living and aging with HIV into the future included experiences of acceptance, uncertainty, anxiety, and hope. Recommendations are made, including developing clinical practice to consider needs relating to social and psychological well-being, as well as physical well-being, for women aging with HIV.

Sleep Disturbance Mediates the Associations Between HIV Stigma and Mental and Physical Health Among Black Adults with HIV

OBJECTIVES

Black Americans have been disproportionally affected by the HIV epidemic, and experience significant disparities in sleep health, mental health, and physical health domains. Using longitudinal data from a sample of Black adults with HIV, the current study examined the associations between stigma and mental and physical health outcomes and how sleep disturbance may play a mediating role.

METHODS

Data were drawn from a recent randomized controlled trial. Questionnaires were used to examine internalized and anticipated HIV stigma, perceived discrimination (enacted stigma) based on multiple social identities (i.e., HIV-serostatus, race, sexual orientation), sleep disturbance, mental health problems (depressive and posttraumatic stress disorder [PTSD] symptoms), and mental and physical health-related quality of life (HRQOL) at baseline, 7-month follow-up, and 13-month follow-up assessments. Linear mixed modeling was used to examine main effects of stigma on health outcomes; causal mediation analysis was used to estimate indirect paths through sleep disturbance.

RESULTS

Internalized and anticipated HIV stigma and multiple discrimination were associated with more sleep disturbance, more depressive and PTSD symptoms, and poorer mental and physical HRQOL. Results also indicated significant indirect paths (i.e., mediation) through greater sleep disturbance between HIV-related stigma and discrimination and mental health and health-related quality of life.

CONCLUSIONS

Results support that sleep disturbance is a mediating pathway through which different forms of stigmas impact health outcomes. Sleep may be an intervention target to help improve mental and physical well-being and reduce health disparities among racial and ethnic minority people with HIV.

Health-related quality of life in reproductive-age women on antiretroviral therapy: a cross sectional study in Ethiopia

OBJECTIVES

While numerous studies have explored the impact of gender on Health-Related Quality of Life (HRQOL), there is a lack of evidence specifically among reproductive-age women undergoing Antiretroviral Therapy (ART). Therefore, this study aims to investigate HRQOL and its associated factors among reproductive-age women receiving ART at Hiwot Fana Comprehensive Specialized Hospital in Eastern Ethiopia.

METHODS

A cross-sectional study included 418 women of ART. The World Health Organization quality of Life Questionnaire (WHOQOL-HIV BREF) was used to assess HRQOL. Binary logistic regression was used to determine the factors that could predict HRQOL.

RESULTS

The study found that the median age of the participants was 37 years, and the overall percentage of women with good HRQOL was 40.7%. Women who stayed on ART for more than 6 years had higher odds of overall good HRQOL (AOR 6.73, 95% CI 3.31-13.71) compared to those with a duration of 6 years or less. Besides, women having no child (AOR 25.03, 95% CI 4.93-127.06), one child (AOR 18.60, 95% CI 3.95-87.65), two children (AOR 12.89, 95% CI 3.66-45.37) and three children (AOR 3.77, 95% CI 1.06-13.34) had higher odds of overall good HRQOL compared to those with four/more children.

CONCLUSIONS

The study found that the majority of women on ART had poor HRQOL. Factors such as longer duration of taking ART, higher CD4+ cell count, disclosure of HIV status, and receiving care from adherence support teams were associated with better quality of life. Thus, strengthening adherence support teams, promoting safe disclosure of HIV status, and providing comprehensive support for HIV-positive women are required to improve their overall HRQOL.

Prevalence of HIV-related stigma manifestations and their contributing factors among people living with HIV in Sweden - a nationwide study

BACKGROUND

With access to  antiretroviral therapy (ART) HIV infection is a chronic manageable condition and non-sexually transmissible. Yet, many people living with HIV still testify about experiencing HIV-related stigma and discrimination. It is well-documented that HIV-related stigma and discrimination continue to be critical barriers to prevention, treatment, care and quality of life. From an individual stigma-reduction intervention perspective, it is essential to identify individual and interpersonal factors associated with HIV-related stigma manifestations. To address this issue and to expand the literature, the aim of this study was to assess the prevalence of HIV-related stigma manifestations and their associated factors among a diverse sample of people living with HIV in Sweden.

METHOD

Data from 1 096 participants were derived from a nationally representative, anonymous cross-sectional survey "Living with HIV in Sweden". HIV-related stigma manifestations were assessed using the validated Swedish 12-item HIV Stigma Scale encompassing four HIV-related stigma manifestations: personalised stigma, concerns with public attitudes towards people living with HIV, concerns with sharing HIV status, and internalized stigma. Variables potentially associated with the HIV-related stigma manifestations were divided into four categories: demographic characteristics, clinical HIV factors, distress and ART adherence, and available emotional HIV-related support. Four multivariable hierarchical linear regression analyses were employed to explore the associations between multiple contributors and HIV-related stigma manifestations.

RESULTS

The most dominating stigma feature was anticipation of HIV-related stigma. It was manifested in high scores on concerns with sharing HIV status reported by 78% of the participants and high scores on concerns about public attitudes towards people living with HIV reported by 54% of the participants. High scores on personalised stigma and internalized stigma were reported by around one third of the participants respectively. Between 23 and 31% of the variance of the four reported HIV-related stigma manifestations were explained mainly by the same pattern of associated factors including female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support.

CONCLUSION

The most dominating stigma feature was anticipation of stigma. Female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support constituted potential vulnerability factors of the four HIV-related stigma manifestations. Our findings highlight the vital necessity to support people living with HIV to increase their resilience to stigma in its different forms. Exploring associated factors of HIV-related stigma manifestations may give an indication of what circumstances may increase the risk of stigma burden and factors amenable to targeted interventions. As individual stigma-reductions interventions cannot be performed isolated from HIV-related stigma and discrimination in society, a key challenge is to intensify anti-stigma interventions also on the societal level.

The Association of Mental Health and Substance Use With Retention in HIV Care Among Black Women in Washington, District of Columbia

BACKGROUND

Black women with HIV are impacted by mental health and substance use disorders alongside barriers to care. The impact of these disorders on retention in care, a crucial step of the HIV care continuum, has not been well-studied. We examined the association between these disorders and retention in care over a 2-year period.

METHODS

Data from January 1, 2011, to June 30, 2019, were obtained from the DC Cohort, an observational HIV study in Washington, District of Columbia. We examined the associations between mental health (i.e., mood-related or trauma-related) or substance use disorders, separately, on not being retained in HIV care over a 2-year interval post-enrollment among non-Hispanic Black women with HIV. Multivariate logistic regression with adjusted odds ratios (aORs) for sociodemographic and clinical variables was used to quantify the association of 1) having a confirmed mental health or substance use disorder and 2) not being retained in care.

RESULTS

Among the 2,181 women in this analysis, 690 (31.64%) were not retained in care. The prevalence of a mood-related disorder (39.84%) was higher compared with a substance use (16.19%) or trauma-related disorder (7.75%). Age per a 10-year increase (aOR 0.87; confidence interval [CI] 0.80, 0.94) and a mood-related disorder diagnosis (aOR 0.72; CI: 0.59, 0.88) were inversely associated with not being retained in care.

CONCLUSION

Mood-related disorders were prevalent among Black women with HIV in Washington, District of Columbia, but were not associated with worse retention in care. Future studies should examine key facilitators for Black women with HIV and coexisting mood-related disorders and how they impact retention in care.

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.

Resisting and disrupting HIV-related stigma: a photovoice study

BACKGROUND

The stigma associated with human immunodeficiency virus (HIV) is a significant global public health concern. Health care providers and policy makers continue to struggle with understanding and implementing strategies to reduce HIV-related stigma in particular contexts and at the intersections of additional oppressions. Perspectives and direction from people living with HIV are imperative.

METHODS

In this project we amplified the voices of people living with HIV about their experiences of HIV-related stigma in Manitoba, Canada. We used an arts-based qualitative case study research design using photovoice and narrative interviews. Adults living with HIV participated by taking pictures that represented their stigma experiences. The photos were a catalyst for conversations about HIV and stigma during follow-up individual narrative interviews. Journaling provided opportunities for participants to reflect on their experiences of, and resistance to, stigma. Interviews were audio recorded and transcribed. Photos, journals, and transcribed interviews were analyzed using inductive qualitative methods RESULTS: Through pictures and dialogue, participants (N = 11; 64% women) expressed the emotional and social impacts of stigmas that were created and supported by oppressive structures and interpersonal attitudes and behaviours. These experiences were compounded by intersecting forms of oppression including racism, sexism, and homophobia. Participants also relayed stories of their personal strategies and transitions toward confronting stigma. Strategies were themed as caring for oneself, caring for children and pets, reconstituting social support networks, and resisting and disrupting stigma. Participants made important recommendations for system and policy change.

CONCLUSIONS

These stories of oppression and resistance can inspire action to reduce HIV-related stigma. People living with HIV can consider the strategies to confront stigma that were shared in these stories. Health care providers and policy makers can take concerted actions to support peoples' transitions to resisting stigmas. They can facilitate supportive and anti-oppressive health and social service systems that address medical care as well as basic needs for food, shelter, income, and positive social and community connections.

The Effect of the Shikamana Peer-and-Provider Intervention on Depressive Symptoms, Alcohol Use, and Other Drug Use Among Gay, Bisexual, and Other Men Who Have Sex with Men in Kenya

Kenyan gay, bisexual, and other men who have sex with men (GBMSM) face stigma and discrimination, which may adversely impact mental health and limit antiretroviral therapy (ART) adherence among GBMSM living with HIV. We evaluated whether the Shikamana peer-and-provider intervention, which improved ART adherence among participants in a small randomized trial, was associated with changes in mental health or substance use. The intervention was associated with a significant decrease in PHQ-9 score between baseline and month 6 (estimated change - 2.7, 95% CI - 5.2 to - 0.2, p = 0.037) compared to standard care. In an exploratory analysis, each one-point increment in baseline HIV stigma score was associated with a - 0.7 point (95% CI - 1.3 to - 0.04, p = 0.037) greater decrease in PHQ-9 score over the study period in the intervention group. Additional research is required to understand factors that influence this intervention's effects on mental health outcomes.

The cost of anticipating stigma: a longitudinal examination of HIV stigma and health

Levels of HIV stigma remain high, however there is a limited understanding around how different types of stigma interact to impact health. This study uses data from two time points to examine how enacted and internalized stigma lead to worse health through anticipated stigma as a mediator. We recruited 341 participants in Ontario, Canada to complete the HIV Stigma Index survey at baseline (t₁) from September 2018 to August 2019 and follow up (t₂) approximately two years later. Mediation models were created with enacted and internalized stigma at t₁ as the antecedents, anticipated stigma at t₂ as the mediator, and physical health, mental health, and overall health at t₂ as the outcomes. Only the model with internalized stigma (t₁) as the antecedent had anticipated stigma (t₂) as a significant mediator contributing to both decreased mental and overall health. This highlights the need to address internalized stigma and the potential for anticipated stigma interventions to be effective at improving the health and wellbeing of people living with HIV.

Psychological pathways to HIV-related posttraumatic stress disorder symptoms among people living with HIV in China: the mediating role of rumination

The occurrence of HIV-related posttraumatic stress disorder (PTSD) compromises the physical and mental health of people living with HIV (PLWH). This study examined the psychological pathways of HIV-related PTSD symptoms considering the influence of rumination in PLWH of China. A cross-sectional survey was conducted in Changsha, China. The data were collected using the PTSD Checklist-Civilian Version, the Ruminative Response Scale, the Multidimensional Scale of Perceived Social Support, and measures of sociodemographic and HIV-related clinic characteristics. A total of 602 PLWH were surveyed. The average score of HIV-related PTSD symptoms was (34.54 ± 13.58). The mediation model showed that perceived social stigma and physical health exhibited direct associations with PTSD symptoms (β = 0.093, -0.145, respectively), while the direct relations of family support, friend support and significant others support to PTSD symptoms were not significant. Rumination mediated the effect of perceived social stigma (β = 0.077), physical health (β = -0.150), family support (β = -0.144) and friend support (β = -0.105) on PTSD symptoms. The study findings underscore the importance of routinely assessing PTSD for PLWH, and developing trauma-focused interventions that alleviate HIV-related PTSD symptoms and reduce rumination while improving social support and physical health and reducing social stigma.

Using Network Analysis to Assess the Effects of Trauma, Psychosocial, and Socioeconomic Factors on Health Outcomes Among Black Women Living with HIV

Black women living with HIV (BWLWH) face intersectional adversities impacting their wellbeing. This study utilized network analysis to assess the associations among adversities linked to racism, sexism, HIV stigma, and socioeconomic status (income, housing, education) and determine which adversities predict mental health outcomes, HIV viral load, and medication adherence more consistently among BWLWH. 119 BWLWH aged 18 years or older completed self-report measures on sociodemographics, adversity factors, and mental health outcomes. Viral load count was obtained through blood draws, and medication adherence was measured via Wisepill adherence monitoring device. Multiple regression analysis was used to assess if the more central factors in the network also predicted health outcomes more consistently than the less central factors. The four most central factors in the network were income, housing, gendered racial microaggression (GRM) frequency, and GRM appraisal. Multiple regression analysis revealed that GRM frequency, GRM appraisal, and the number of traumas contributed uniquely and were positively associated with both depressive symptoms and posttraumatic stress disorder symptoms. HIV-related discrimination contributed uniquely and was positively associated with HIV viral load.

Self-esteem, adverse life events, and mental health diagnoses among Black women living with HIV

PURPOSE

Black women in the U.S. are disproportionately impacted by HIV and adverse life events (ALE). High self-esteem has been noted as a protective factor and low self-esteem has been linked to mental health diagnoses. However, the existing literature is limited in the examination of how self-esteem may buffer relationships between ALE and mental health diagnoses among Black women living with HIV (BWLWH).

METHODS

One hundred and nineteen BWLWH completed self-report measures on self-esteem (Rosenberg Self-Esteem Scale) and ALE (Life Events Checklist for DSM-5) (e.g. sexual assault, physical assault, accidents, natural disaster) as well as a clinical interview (via Mini-International Neuropsychiatric Inventory) to diagnose current depression, PTSD, and suicidality.

RESULTS

Multivariable logistic regressions indicated that higher self-esteem was associated with lower likelihood of current depression (OR = .894, p < .01), PTSD (OR = .838, p < .001) and suicidality (OR = .889, p < .05). Interactions between self-esteem and total ALE significantly predicted current depression (OR = .000003, p < .05) and PTSD (OR = 2.7182 × 10-9, p < .001); and higher total ALE related to higher likelihood of current PTSD only among BWLWH reporting lower self-esteem (OR = 1.21, p < .05).

CONCLUSION

Interventions addressing mental health diagnoses among BWLWH should incorporate strategies to enhance self-esteem.

Addressing Women’s Needs with Human Immunodeficiency Virus (HIV) and Enhancing the Visibility of Pharmacists in the Public Health Arena

Human Immunodeficiency Virus (HIV) continues to have a staggering effect on women’s lives in the United States (U.S.). Women Living With HIV (WLWH) face many challenges, such as mental health disorders, compared to their male counterparts. These diagnoses make women more disproportionally affected, and meaningful healthcare interventions must address these conditions. This review has three foci: WLWH in the U.S., their access to care and staying in care once antiretroviral treatment has been initiated, coping with mental health, and the role of the U.S. pharmacists in access to the treatment. Pharmacists are the most easily accessible healthcare profession in the U.S. For example, 93% of American customers live within 5 miles of a community pharmacy. Pharmacists are the last healthcare provider with whom the patient interacts before a medication is dispensed; thus, they are in an ideal position to intervene. Engaging pharmacists to provide care for patients with chronic disease states such as HIV has resulted in positive outcomes. Although there are global and U.S. studies that emphasize the role of pharmacists in directing care for persons living with HIV, there is a lack of studies conducted about the role of pharmacists in managing mental health. Future research must address WLWH and mental health conditions to develop targeted interventions from an interdisciplinary team perspective.

Does HIV Stigma Predict Social Networks Over Time: A Latent Growth Curve Analysis

Persons living with HIV (PLWH) with socio-economic vulnerabilities are especially vulnerable to HIV stigma and adverse HIV outcomes. Stigma related to HIV may intersect with marginalized socio-economic conditions to negatively affect social networks. HIV stigma may limit the ability of individuals to sustain social relationships. This study examined the potential cross-sectional and longitudinal associations between HIV stigma and the quality and quantity of social networks for PLWH. PLWH (n = 1,082) who were experiencing housing, employment, and medical care-related difficulties were recruited to participate in a one-year navigation and system coordination intervention to improve housing stability and employment. Neither stigma reduction nor social networks were the main components of the intervention. A series of latent growth curves were estimated to assess the cross-sectional and longitudinal relationships among internalized and anticipated HIV stigma and social networks. Anticipated HIV stigma predicted social networks both cross-sectionally and longitudinally. Internalized HIV stigma predicted social networks cross-sectionally but not longitudinally in this population. These data support the HIV Stigma Framework and suggest that anticipated stigma seems to have a strong association with social networks. As anticipated stigma decreases over time, social network scores increase. Interventions to decrease anticipated HIV stigma as a mechanism of improving social networks warrants further investigation.

Adapting the Health Stigma and Discrimination Framework to understand the association between stigma and sleep deficiency: A systematic review

OBJECTIVE

Sleep deficiency and sleep disorders disproportionally affect socially disadvantaged and marginalized individuals and groups. Recent evidence suggests that stigma, a social process characterized by labeling, stereotyping, and prejudice, is associated with sleep characteristics.

PURPOSE

Guided by the Health Stigma and Discrimination Framework, the purpose of this systematic review is to describe associations between dimensions of stigma and sleep deficiency and to identify future directions for research.

METHODS

We searched the OVIDPsycINFO, OVIDEMASE, OVIDMEDLINE, and CINAHL databases for empirical research studies that reported relationships between the 3 dimensions of stigma-internalized, perceived, and anticipated-and characteristics of sleep deficiency-duration, continuity/efficiency, timing, alertness/sleepiness, quality, and disorders.

RESULTS

Of 1717 articles, 15 met our inclusion criteria. The most frequently assessed dimensions of stigma were internalized and perceived stigma. Characteristics of sleep deficiency were measured by self-report and included sleep quality, duration, trouble sleeping, and insomnia symptoms. We found consistent evidence that stigma, whether internalized, perceived, or anticipated, is associated with self-reported characteristics of sleep deficiency.

CONCLUSIONS

This evidence base can be further strengthened with prospective studies that incorporate both multidimensional measures of stigma and objective measures of sleep characteristics. We outline research implications that can clarify underlying mechanisms and more precisely define the relationships between stigma and sleep and inform interventions to address stigma, improve sleep, and reduce the health inequities that disproportionately affect individuals from socially disadvantaged and marginalized groups.

Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension

Stigma is one of the most harmful forces affecting population health. When stigma exists in clinical settings, environments that should be pro-patient and stigma-free, stigma may become internalized and affect patients' well-being. Informed by prior stigma research and the Intergroup Contact Theory, the authors elucidate statistical relationships between patients' perceptions of clinic-based stigma and stigma's impact on health among New York City's diverse residents. The authors hypothesize that perceiving stigma in clinical settings would mediate the relationships between depression, general health, diabetes, and hypertension; they tested this through multiple logistic regressions conducted on pooled data from the New York City Community Health Survey (N = 18,596, 2016-2017). Among women, depression was associated with stigma (α = 4.07, P < 0.01), hypertension (γ = 2.31, P < 0.01), diabetes (γ = 2.18, P < 0.01), and poor general health (γ = 6.34, P < 0.01). Among men, depression was associated with stigma (α = 3.7, P < 0.01), hypertension (γ = 2.35, P < 0.01), diabetes (γ = 1.86, P < 0.01), and poor general health (γ = 5.14, P < 0.01). Overall, perceived stigma in clinics significantly increased adjusted odds of self-reporting poor general health (adjusted ORs [AOR] = 1.87 men; AOR = 2.05 women). Findings contribute to the literature on the Intergroup Contact Theory, which suggests that stigma should be low in diverse communities; findings indicate that stigma may be a mediator, justifying inclusion in epidemiological and health services research. In addition, study outcomes suggest that depression may be associated with clinic-based stigma, and this stigma has deleterious effects on physical health. Thus, clinicians should emphasize stigma reduction in their facilities, potentially through the adoption of trauma-informed approaches or delivery of care using non-stigmatizing communication strategies, such as Motivational Interviewing.

Association of Poor Sleep With Depressive and Anxiety Symptoms by HIV Disease Status: Women's Interagency HIV Study

BACKGROUND

Sleep disturbances are prevalent in women living with HIV (WLWH) and can affect mental health and overall quality of life. We examined the prevalence and predictors of poor sleep quality in a US cohort of WLWH and HIV-uninfected controls and the relationship between sleep quality and mental health symptom burden stratified by HIV disease status (viremic WLWH, aviremic WLWH, and HIV-uninfected women).

METHODS

Sleep quality was assessed using the Pittsburgh Sleep Quality Index in 1583 (400 viremic WLWH, 723 aviremic WLWH, and 460 HIV-uninfected women) Women's Interagency HIV Study participants. Depressive and anxiety symptoms were concurrently assessed using the Center for Epidemiological Studies-Depression (CES-D) scale and General Anxiety Disorder (GAD-7) scale. Associations between poor sleep quality (global Pittsburgh Sleep Quality Index >5) and both high depressive (CES-D ≥16) and anxiety (GAD-7 ≥10) symptoms were each assessed by HIV disease status using multivariable logistic regression models.

RESULTS

Prevalence of poor sleep quality in the overall sample was 52%, differed by HIV disease status (P = 0.045), and was significantly associated with high depressive and anxiety symptoms in (1) viremic WLWH, (2) aviremic WLWH, and (3) HIV-uninfected women [CES-D: (1) adjusted odds ratio (aOR) = 7.50, 95% confidence interval (CI): 4.10 to 13.7; (2) aOR = 4.54, 95% CI: 3.07 to 6.73; and (3) aOR = 6.03, 95% CI: 3.50 to 10.4; GAD-7: (1) aOR = 5.20; 95% CI: 2.60 to 10.4, (2) aOR = 6.03; 95% CI: 3.67 to 9.91, and (3) aOR = 6.24; 95% CI: 3.11 to 12.6].

CONCLUSIONS

Poor sleep quality is highly prevalent, as is mental health symptom burden, among WLWH and HIV-uninfected controls. Future longitudinal studies are necessary to clarify the directionality of the relationship.

Nutritional Status and Health Characteristics of People Living with HIV/AIDS

Background: Diagnosis and treatment of HIV infection may impact the individual's life, including the physical aspect such as the length of HIV diagnosed, WHO stage, the ART, and the psychological aspect such as the level of stress. People living with HIV/AIDS (PLWHA) have an increased need for energy but they have symptoms of lack of nutrition intake. Therefore, PLWHA has a risk of low nutrition status. The aims of this study were to examine the relationship between nutritional status and health characteristics among HIV/AIDS patients. Methods: A cross-sectional analytical design was conducted among people living with HIV/AIDS (PLWHA) in outpatients’ hospital. A purposive sampling method was used and the sample size was 78 respondents. Data were collected using questionnaire of were the socio-demographic, health characteristic, and nutritional status. The cross-tabulation calculations used chi-square were presented to identify the relationship between nutritional status and health characteristics. Results: The majority of respondents had good health characteristics include the length of HIV diagnosis more than 6 months (79.5%), clinical WHO stage I (61.5%), no stress level (94.9%), and the first choice of ART (83.3%). The nutritional status reported that the majority of the respondents had normal BMI (61.5%), MUAC not at risk (>23,5 cm) (71.8%), and a moderate level of energy intake (37.2%). There were no significant associations between the nutritional status and health characteristics (p > 0.05). Conclusion: The good condition of health characteristics among PLWHA in this study impacted the level the nutritional status.

Attitudes toward a mindfulness-based intervention from African American women living with HIV: A qualitative study

Introduction:

Mindfulness-based interventions train participants to pay attention to their own emotions in the current moment without judging themselves. This study aims to assess the attitudes toward a mindfulness-based stress reduction intervention among African American women living with HIV.

Methods:

We collected qualitative data from three focus group discussions with 18 African American women living with HIV who were purposely recruited from the Palmetto Health-USC Immunology Center in South Carolina, United States. The participants discussed how they coped with stress, and then were given a presentation on mindfulness-based stress reduction and a sample mindfulness-based stress reduction mini workshop with follow-up discussion about their thoughts and opinions on the information presented to them.

Results:

Participants said that mindfulness could be a useful technique and they were interested in participating in a mindfulness-based stress reduction program. Their main concerns included physical ability to perform some of the mindfulness techniques (e.g. yoga) and logistic barriers, such as schedule constraints. They also provided some suggestions to further tailor the mindfulness-based stress reduction, such as modifying yoga, using familiar terms, and combining both in-person and online components. These results suggest that African American women living with HIV showed strong interest in mindfulness-based stress reduction and a high level of willingness to participate in mindfulness-based stress reduction, but the existing mindfulness-based stress reduction program needs to be tailored to address challenges and barriers these women may face for attendance and completion.

Conclusion:

The next step is to further test the feasibility, acceptability, and efficacy through a pilot study for African American women living with HIV to practice a tailored mindfulness-based stress reduction for this group.

Pathways to Depression and Poor Quality of Life Among Adolescents in Western Kenya: Role of Anticipated HIV Stigma, HIV Risk Perception, and Sexual Behaviors

Depression is a major cause of disease burden and is linked to poor quality of life (QOL) among adolescents. We examined the roles of sexual behaviors, HIV risk perception, and anticipated HIV stigma on depressive symptomatology and QOL among 4096 adolescents in a rural region of western Kenya with a high burden of HIV. Participants were aged 15-19 years, had not been tested for HIV in the previous 6 months, and had never been diagnosed with HIV. Anticipated stigma and risk perception were directly associated with depressive symptomatology and QOL. There was evidence of small indirect effects-through stigma-of risk perception on depressive symptomatology and QOL. Gender moderated relationships between sexual behavior and risk perception, depressive symptomatology, and QOL. Results suggest that developing effective gender-based interventions to address stigma, sexual behavior, and risk perception may be important for improving adolescent well-being in high HIV prevalence contexts.

HIV-related stigma and health-related quality of life in women living with HIV in developed countries: a systematic review

HIV-related stigma has been shown to negatively affect the health-related quality of life (HRQoL) in people living with HIV. Women living with HIV (WLWH) suffer greater consequences from stigma on multiple health outcomes when compared to men. The objective of this review was to examine the association between HIV-related stigma and HRQoL in WLWH in developed countries. A systematic search was conducted in three medical databases. The PRISMA guideline was used as a methodical frame of reference, and the STROBE checklist as a quality assessment tool. Eight studies on a total of 2903 WLWH were included. All studies were cross-sectional of design and published between 2011-2019. All studies found a negative and statistically significant association between HIV-related stigma and HRQoL. The association was found to be weak to moderate in strength when examined using correlations statistics. Heterogeneity across the choice of measures and variables examined in the included studies made comparison difficult. Risk of bias was deemed present in majority of studies. Thus, this review reveals a negative association between HIV-related stigma and HRQoL in WLWH in developed countries. The association appears to be influenced by a range of complex factors, such as psychosocial variables and sociodemographic determinants.

Reducing HIV Risk Behaviors Among Black Women Living With and Without HIV/AIDS in the U.S.: A Systematic Review

This systematic review provides an examination of the status of HIV/AIDS prevention interventions for Black, heterosexual women in the U.S. from 2012 to 2019. Using PRISMA guidelines, 28 interventions were identified. Over half of the interventions were: conducted in the southern region of the U.S.; evaluated using a randomized controlled trial; focused on adults; used a group-based intervention delivery; were behaviorally focused and theoretically driven. None included biomedical strategies of PrEP, nPEP, and TasP. Few interventions included adolescent or aging Black women; none included their sex/romantic partners. Future studies dedicated to addressing the specific needs of subpopulations of Black, heterosexual women may provide opportunities to expand and/or tailor current and future HIV/AIDS prevention interventions, including offering participants with options to choose which, and the level of involvement, of their sex/romantic partner(s) in their sexual health decision-making. While strides to improve HIV prevention efforts with Black, heterosexual women have occurred, more is needed.

Psychiatric Disorders and Substance Use Among African American Women in HIV Care

African-American (AA) women are overrepresented among women with HIV (WWH). In the United States, psychiatric disorders are prevalent among WWH and associated with adverse outcomes. However, little research has examined psychiatric disorders among AA WWH. 315 AA women who were hazardous/heavy drinkers (HD) or moderate/non-drinkers (ND) were recruited from an HIV clinic in a study on alcohol use disorders. We compared sample prevalence of Axis-1 psychiatric diagnoses using the Structured Clinical Interview for DSM-IV with those from general population AA women in the National Comorbidity Survey-Replication (NCS-R). While 29.9% of general population AA women had any lifetime disorder, 66.9% of HD and 62.4% of ND WWH met criteria for a lifetime Axis-1 disorder. Specifically, lifetime PTSD and lifetime MDD were over threefold higher; current PTSD and current MDD respectively were 11-fold and threefold higher. PTSD was the most frequent comorbid diagnosis. HD and ND WWH did not differ in prevalence of psychiatric diagnoses despite significantly higher rates of substance use among HD women. Diagnostic evaluation and intervention for psychiatric disorders should be a priority in HIV medical care settings to improve health outcomes. Interventions should be tailored to address the particular stressors, challenges, and resiliencies among AA WWH.

'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.

Social Determinants of Potential eHealth Engagement Among People Living with HIV Receiving Ryan White Case Management: Health Equity Implications from Project TECH

OBJECTIVES

Evaluate the relationships between social characteristics of Floridian persons living with HIV (PLWH) and both use of digital technologies and willingness to use eHealth for HIV-related information.

METHODS

Ryan White case managers (N = 155) from 55 agencies in 47 Florida counties administered a survey to PLWH (N = 1268) from June 2016-April 2017. Multilevel logistic regression models were used to identify correlates of technology use and willingness.

RESULTS

Use of mobile phones with text messaging was high (89%). Older (vs. younger) adults and non-Hispanic blacks (vs. whites) were less likely to use most technologies. These groups, along with Hispanics (vs. whites) were less likely to express willingness to use technologies for HIV-related information in models adjusting for use.

CONCLUSIONS

Among PLWH in Florida, eHealth-related inequities exist. Willingness to engage in HIV-related eHealth is affected by social determinants, even when considering technology access. Although eHealth may reduce some healthcare inequities, it may exacerbate others.

Religiosity, Social Support, and Ethnic Identity: Exploring "Resilience Resources" for African-American Women Experiencing HIV-Related Stigma

INTRODUCTION

African-American women living with HIV report substantial HIV-related stigma and depression. Resilience resources are strength-based resources that may moderate the effects of HIV-related stigma on poor psychosocial outcomes such as depression.

OBJECTIVE

To evaluate whether religiosity, social support, and ethnic identity moderate the effects of HIV-related stigma on depression among African-American women living with HIV.

METHODS

We used baseline data (May 2013-October 2015) from a randomized controlled trial testing the efficacy of an HIV-related stigma-reduction intervention among African-American women living with HIV in Chicago, IL, and Birmingham, AL, who were older than 18 years and currently receiving HIV services. To assess whether religiosity (7-item Religious Beliefs and Behaviors survey), social support (select subscales from the Medical Outcomes Study Social Support Survey), and ethnic identity (Commitment subscale from the Multigroup Ethnic Identity Measure) modified the relationship between HIV-related stigma (Stigma Scale for Chronic Illness) and depression (8-item Patient Health Questionnaire), we conducted 3 separate moderation analyses using linear regression with interactions between HIV-related stigma and each moderator of interest, adjusted for study site, age, time since diagnosis, and education.

RESULTS

Among 226 African-American women living with HIV, greater levels of HIV-related stigma were associated with greater depression in all 3 models (P < 0.05). Only religiosity modified this association (P = 0.04), with a weaker association among women reporting higher levels of religiosity.

CONCLUSIONS

The protective effects of religiosity may be leveraged in interventions for African-American women living with HIV struggling with HIV-related stigma.

Assessing the Efficacy of a PhotoVoice-Informed HIV Stigma Training for Health Care Workers

HIV stigma is a harmful social phenomenon present in United States (US)-based health care settings. This study assessed the efficacy of a participatory PhotoVoice-informed stigma reduction training program focusing on people living with HIV (PLWH) and targeting health care workers. Seventy-three (N = 73) participants were assessed at baseline (T1), within approximately a week of the training (T2), and at a 3-month follow-up (T3) regarding their HIV/AIDS knowledge, attitudes towards PLWH, and observations of enacted HIV stigma. Findings indicated that the training increased knowledge and improved attitudes (β = 0.56, p < 0.01; β = 0.58, p < 0.01, respectively) at T2, but these effects diminished at T3 (β = - 0.03, p > 0.05; β = - 0.29, p > 0.05, respectively). The training did not, however, have an impact on observations of enacted stigma at T2 (β = 0.10, p > 0.05) or at T3 (β = 0.02, p > 0.05). Additional participatory stigma reduction programs that involve diverse groups of health care workers, offer salient study incentives, include time-saving training methods, and comprise a variety of stigma measures, may be particularly beneficial.

“I Don’t Know and I Don’t Want to Know”: A Qualitative Examination of Older African American Women’s Knowledge and Experiences With HIV

While older African American women (e.g., aged 50 years and older) comprise only 11% of the female population in the United States, they account for 50% of HIV diagnoses among women in this age group. Unique sociocultural factors, including a lack of HIV knowledge and stigma, contribute to HIV risk among older African American women. The goal of this qualitative study was to obtain a nuanced perspective from older African American women about HIV knowledge and experiences with HIV using the framework of intersectionality theory. Focus groups were conducted with 35 African American women who were 50 years and older, nonpartnered, and heterosexual. Women were asked what they knew about HIV and if they thought older women were at risk for HIV. A thematic analysis using NVivo 11 yielded two central themes and three subthemes: HIV knowledge, including experiential knowledge, superficial knowledge, and no knowledge, and stigma around HIV in the Black church. Implications for developing HIV prevention programs and testing messages are discussed.