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

Associations of Minority Stressors, Alcohol Use Disorder, Resilience, and HIV Testing Self-Efficacy Among Community-Based Black Men Who Have Sex with Men in a Southern U.S. City: A Causal Mediation and Moderation Analysis

Background: Black men who have sex with men (BMSM) face multiple minority stressors (e.g., homophobia, racism, and presumed HIV status) that may indirectly erode their confidence in pursuing HIV testing uptake through exacerbating alcohol use disorder (AUD). Objectives: Using cross-sectional data from 203 community-based BMSM (71.4% as homosexual with a mean age of 26 years) living in a Southern US city, we conducted a causal mediation and moderation analysis to investigate in/direct pathways linking minority stressors, AUD risk, and self-efficacy of HIV testing, including how resilience may moderate these associations. Results: Our mediation analysis revealed that AUD risk accounted for 32.1% of the total effect of internalized homonegativity (βtotal effect = -0.424; SE=0.071; p<0.001), 28.6% of the total effect of experienced homophobia (βtotal effect = -0.684; SE=0.122; p<0.001), and 15.3% of the total effect of perceived HIV stigma (βtotal effect = -0.361; SE=0.164; p<0.05) on HIV testing self-efficacy. Resilience significantly moderated the associations of experienced homophobia (β = -0.049; SE=0.011; p<0.001), internalized homonegativity (β = -0.065; SE=0.027; p<0.01), and perceived HIV stigma (β = -0.034; SE=0.013; p<0.05) with AUD risk. Resilience also significantly moderated the associations of experienced homophobia (β = -0.073; SE=0.021; p<0.01), internalized homonegativity (β = -0.082; SE=0.012; p<0.001), perceived HIV stigma (β = -0.037; SE=0.039; p<0.05), and AUD risk (β = -0.021; SE=0.015; p<0.05) with HIV testing self-efficacy. Conclusions: Our study provides important implications in identifying multilevel sources for building resilience among BMSM to buffer the effects of minority stress on AUD risk and improve HIV testing outcomes.

The Impact of HIV-Related Stigma on Racial/Ethnic Disparities in Retention in HIV Care Among Adults Living with HIV in Florida

BACKGROUND

Our study examines the effects of distinct HIV stigma subtypes on retention in care and racial-ethnic differences among persons with HIV (PWH).

METHODS

Using Florida Medical Monitoring Project 2015-2017 data, we analyzed patients' clinical and behavioral characteristics. We analyzed 89,889 PWH in Florida (50.0% non-Hispanic Blacks, 20.8% Hispanics, 29.2% non-Hispanic whites). HIV stigma subtypes, negative self-image, anticipated stigma, personalized stigma, and retention in care were examined with logistic regressions.

RESULTS

People with high negative self-image and anticipated stigma were less likely to be retained (CI: 0.84-0.92; 0.47-0.53). The association between HIV-related stigma subtypes and retention in care differed between Black, White, and Hispanic participants. Negative self-image was associated with higher retention rates among Hispanics (CI: 5.64-9.26) and Whites (CI: 1.04-1.27), while low retention rates among Blacks (0.617-0.686). The likelihood of staying in care was lower across all racial-ethnic groups when the anticipated stigma was high or moderate. In contrast, personalized stigma increased retention across all racial-ethnic groups.

CONCLUSION

Results showed that distinct types of HIV stigma differentially impact retention, and these associations differ by race and ethnicity. Future interventions should address the effect HIV stigma subtypes have on racially minoritized PWH retention.

Multilevel Resilience and HIV Virologic Suppression Among African American/Black Adults in the Southeastern United States

OBJECTIVE

To assess overall and by neighborhood risk environments whether multilevel resilience resources were associated with HIV virologic suppression among African American/Black adults in the Southeastern United States.

SETTING AND METHODS

This clinical cohort sub-study included 436 African American/Black participants enrolled in two parent HIV clinical cohorts. Resilience was assessed using the Multilevel Resilience Resource Measure (MRM) for African American/Black adults living with HIV, where endorsement of a MRM statement indicated agreement that a resilience resource helped a participant continue HIV care despite challenges or was present in a participant's neighborhood. Modified Poisson regression models estimated adjusted prevalence ratios (aPRs) for virologic suppression as a function of categorical MRM scores, controlling for demographic, clinical, and behavioral characteristics at or prior to sub-study enrollment. We assessed for effect measure modification (EMM) by neighborhood risk environments.

RESULTS

Compared to participants with lesser endorsement of multilevel resilience resources, aPRs for virologic suppression among those with greater or moderate endorsement were 1.03 (95% confidence interval: 0.96-1.11) and 1.03 (0.96-1.11), respectively. Regarding multilevel resilience resource endorsement, there was no strong evidence for EMM by levels of neighborhood risk environments.

CONCLUSIONS

Modest positive associations between higher multilevel resilience resource endorsement and virologic suppression were at times most compatible with the data. However, null findings were also compatible. There was no strong evidence for EMM concerning multilevel resilience resource endorsement, which could have been due to random error. Prospective studies assessing EMM by levels of the neighborhood risk environment with larger sample sizes are needed.

Adaptive Stigma Coping Among Papuans Living with HIV: a Qualitative Study in One of the Indigenous People, Indonesia

INTRODUCTION

The indigenous Papuans of Indonesia's Tanah Papua Island have been a distinct cultural and racial entity from the rest of the country's inhabitants. Furthermore, antiretroviral therapy's inability to reduce mortality and incidence rates in this region has sparked public interest in HIV issues, which has resulted in increased stigma. Papuans were more interested in memorizing the symptoms than using antiretroviral as an effective therapy. This study aimed to analyze the coping level of HIV-infected Papuans to overcome related stigma.

METHODS

A qualitative study was conducted with data collected through semi-structured interviews in 2018, and 13 Papuans who had experiences with antiretroviral therapy (ART) participated in audio-recorded interviews. The discussions were focused on the ways to deal with stigma after the HIV diagnosis. Furthermore, data were transcribed verbatim using the framework analysis for qualitative study.

RESULTS

According to the study results, Papuans were shown to have effectively used self-distancing, self-blame, and self-stigmatization coping mechanisms, according to the results. The people temporarily utilize ART until their health returns to normal.

CONCLUSIONS

This study indicates that ART has been used to cope with stigma. However, the use was temporary since the misunderstanding regarding use of ART remains high. ART education should be addressed since Papuans are willing to adopt the method provided the benefits are fully comprehended. In addition, the participation of healthcare workers such as pharmacies should be increased since they can explain antiretroviral terms.

The ethical imperative to reduce HIV stigma through community-engaged, status-neutral interventions designed with and for transgender women of colour in the United States

INTRODUCTION

In the era of biomedical HIV prevention and treatment technologies, such as treatment as prevention (TasP) and pre-exposure prophylaxis (PrEP), there is momentum to develop and rigorously evaluate interventions focused on PrEP among those at risk for HIV acquisition and antiretroviral therapy (ART) adherence among people living with HIV. While HIV status-specific interventions focused on PrEP or ART provide valuable information, status-segregated interventions can create, perpetuate, and even increase HIV stigma among transgender women of colour and other marginalized communities in the United States (US).

DISCUSSION

Due largely to community advocacy, discourses that support status-neutral approaches have emerged in the scientific literature. Although US-based funding mechanisms have typically designated awards focused on a specific HIV status, intervention developers and implementing agencies find creative ways to design and implement status-neutral programmes despite such restrictions. We present our experience with intervention research in New York, Detroit, New Orleans, Puerto Rico and the San Francisco Bay Area, all Ending the HIV Epidemic (EHE) priority jurisdictions. Kickin it with the Gurlz' was developed to be status-neutral through two grants due to community demands for a unifying approach. The Transgender Women Engagement and Entry to (TWEET) Care Project was designed to improve HIV care engagement for transgender women living with HIV, but developers realized the importance of including participants of any HIV status. Healthy Divas was designed for transgender women living with HIV but subsequent implementing agencies prioritized adapting it to be status-neutral. These examples support the urgency of designing, implementing and evaluating status-neutral interventions.

CONCLUSIONS

Community-based organizations strive for inclusivity in their programming and are rightly often reluctant to segregate services based on the HIV status of their clients. As researchers, we have an ethical imperative to work to reduce HIV stigma and respond to the needs of those most impacted by HIV, including transgender women of colour. As such, we call upon funders to develop mechanisms that support the development and testing of HIV status-neutral interventions to reduce HIV stigma and support community building, thereby increasing the possibility of fully realizing the benefits of biomedical HIV prevention and treatment technologies for all.

Age and Year of HIV Diagnosis are Associated with Perceptions of Discrimination and Internalized Stigma Among Sexual Minority Men Who Use Substances

Discrimination and internalized stigma are barriers to engagement in HIV self-care among men who have sex with men (MSM) living with HIV. However, differences in perceptions of discrimination and internalized stigmas by age, year of HIV-diagnosis, and race are poorly understood. We assessed differences in reported discrimination related to HIV, race, sexual orientation, and substance use and internalized stigmas among 202 MSM living with HIV who use substances. Younger participants reported higher levels of all types of discrimination and internalized stigmas (p-values < 0.001-0.030). Those diagnosed after the advent of antiretrovirals reported higher levels of discrimination related to HIV, sexual orientation, and substance use, as well as internalized stigma related to HIV and substance use (p-values 0.001-0.049). We explored perceived community HIV stigma, which accounted for associations involving age and year of diagnosis. Age, year of diagnosis, and race should be considered when assessing and intervening with stigma.

Mini-review: Elucidating the psychological, physical, and sex-based interactions between HIV infection and stress

Stress is generally classified as any mental or emotional strain resulting from difficult circumstances, and can manifest in the form of depression, anxiety, post-traumatic stress disorder (PTSD), or other neurocognitive disorders. Neurocognitive disorders such as depression, anxiety, and PTSD are large contributors to disability worldwide, and continue to affect individuals and communities. Although these disorders affect men and women, women are disproportionately represented among those diagnosed with affective disorders, a result of both societal gender roles and physical differences. Furthermore, the incidence of these neurocognitive disorders is augmented among People Living with HIV (PLWH); the physical ramifications of stress increase the likelihood of HIV acquisition, pathogenesis, and treatment, as both stress and HIV infection are characterized by chronic inflammation, which creates a more opportunistic environment for HIV. Although the stress response is facilitated by the autonomic nervous system (ANS) and the hypothalamic pituitary adrenal (HPA) axis, when the response involves a psychological component, additional brain regions are engaged. The impact of chronic stress exposure and the origin of individual variation in stress responses and resilience are at least in part attributable to regions outside the primary stress circuity, including the amygdala, prefrontal cortex, and hippocampus. This review aims to elucidate the relationship between stress and HIV, how these interact with sex, and to understand the physical ramifications of these interactions.