Intersectional health-related stigma in persons living with HIV and chronic pain: implications for depressive symptoms

Understanding the link between pain invalidation and depressive symptoms: The role of shame and social support in people with chronic pain

Pain invalidation (e.g., having pain discounted) is a risk factor for depression among people with chronic pain, but the mechanisms remain unclear. Shame is a common, yet understudied, aspect of the pain experience. This study investigated whether pain-related shame helps explain the relationship between pain discounting and heightened depressive symptoms. The secondary aim was to examine whether social support can protect against the harmful effects of discounting. Patients with chronic pain (N = 305) were recruited from outpatient pain clinics. Participants completed an online cross-sectional survey and data were analyzed using moderated mediation analysis. Greater discounting was associated with greater depressive symptoms, and pain-related shame significantly mediated this relationship. Perceived social support attenuated the relationship between discounting and depressive symptoms. Greater attention towards pain-related shame as a treatment target is needed. Individual- and system-level interventions are required to address pain invalidation and bolster support for this population.

Geometric approach to measuring intersectional stigma among black sexual minority men: reliability and validity in an HIV prevention context

BACKGROUND

Stigma and discrimination experiences attributable to multiple intersecting facets of the self (e.g. intersectional stigma) pose substantial challenges to accessing health services, including HIV prevention. While there have been theoretical advances in understanding multiple co-occurring stigmas, there are few psychometric instruments available to assess intersectional stigma. We have developed an approach to assessing intersectional stigma that conceptualises an intersection in geometric terms, defined as the line that connects points on two (or more) stigma dimensions and calculates scores derived from the geometric definition of intersecting lines.

METHODS

Following pilot studies to derive items and response formats, we administered newly developed enacted stigma (24-items) and anticipated stigma (17-items) scales with attributions to race and sexual minority status for stigma experiences to a sample of 422 Black sexual minority men at risk for HIV recruited through social media platforms.

RESULTS

The enacted and anticipated intersectional stigma scales, including subscales representing discrimination, interpersonal and felt stigma demonstrated evidence for reliability and construct validity. The enacted stigma scales were associated with medical mistrust, whereas the anticipated stigma scales predicted perceived barriers to using pre-exposure prophylaxis for HIV prevention.

CONCLUSIONS

The intersectional stigma scales offer greater specificity in measuring stigma experiences attributed to race, sexual minority status and the intersection of racial-sexual minority status.

An Incognito Standardized Patient Approach for Measuring and Reducing Intersectional Healthcare Stigma

Background

Consistent evidence highlights the role of stigma in impairing healthcare access in people living with HIV (PLWH), men who have sex with men (MSM), and people with both identities. We developed an incognito standardized patient (SP) approach to obtain observations of providers to inform a tailored, relevant, and culturally appropriate stigma reduction training. Our pilot cluster randomized control trial assessed the feasibility, acceptability, and preliminary effects of an intervention to reduce HIV stigma, anti-gay stigma, and intersectional stigma.

Methods

Design of the intervention was informed by the results of a baseline round of incognito visits in which SPs presented standardized cases to consenting doctors. The HIV status and sexual orientation of each case was randomly varied, and stigma was quantified as differences in care across scenarios. Care quality was measured in terms of diagnostic testing, diagnostic effort, and patient-centered care. Impact of the training, which consisted of didactic, experiential, and discussion-based modules, was assessed by analyzing results of a follow-up round of SP visits using linear fixed effects regression models.

Results

Feasibility and acceptability among the 55 provider participants was high. We had a 87.3% recruitment rate and 74.5% completion rate of planned visits (N=238) with no adverse events. Every participant found the training content "highly useful" or "useful." Preliminary effects suggest that, relative to the referent case (HIV negative straight man), the intervention positively impacted testing for HIV negative MSM (0.05 percentage points [PP], 95% CI,-0.24, 0.33) and diagnostic effort in HIV positive MSM (0.23 standard deviation [SD] improvement, 95% CI, -0.92, 1.37). Patient-centered care only improved for HIV positive straight cases post-training relative to the referent group (SD, 0.57; 95% CI, -0.39, 1.53). All estimates lacked statistical precision, an expected outcome of a pilot RCT.

Conclusions

Our pilot RCT demonstrated high feasibility, acceptability, and several areas of impact for an intervention to reduce enacted healthcare stigma in a low-/middle-income country setting. The relatively lower impact of our intervention on care outcomes for PLWH suggests that future trainings should include more clinical content to boost provider confidence in the safe and respectful management of patients with HIV.

Correlates of Internalized HIV Stigma: A Comprehensive Systematic Review

Internalized HIV stigma is prevalent and research on internalized HIV stigma has increased during the past 10 years. The aim of this systematic review was to synthesize research on internalized HIV stigma and relationships with various health-related variables in order to better inform the development of interventions aimed at reducing internalized HIV stigma. We reviewed 176 studies with a quantitative design reporting correlates that were peer-reviewed, published in English before January 2021, drawn from PubMed, PSYCHINFO, Web of Science, EBSCO, and Scopus. Synthesis showed consistent associations between internalized stigma and negative psychological (e.g., depression, anxiety), social (e.g., lack of social support, discrimination, nondisclosure, and intersecting stigmas), and health (e.g., substance use, treatment nonadherence, negative clinical HIV outcomes) variables. We argue for a more socioecological approach to internalized stigma, with greater attention for intersectional stigmas, and more longitudinal research, if we are to effectively develop interventions that reduce internalized stigma.

The contribution of psychological flexibility to functioning in people living with cancer-related pain

BACKGROUND

Studies of individuals with non-cancer-related chronic pain find that higher levels of psychological flexibility (PF) are associated with less distress, better functioning, and a better response to treatment. People diagnosed with cancer are at a significantly increased risk of developing chronic cancer-related pain, the presence of which is associated with poorer health outcomes. Little is known about whether PF is applicable to cancer pain. The current study investigates the relationship between chronic cancer-related pain, distress and functioning, and three theoretical processes proposed by the PF model: pain acceptance, present-moment focus, and committed action.

METHODS

Adults (n = 246) with a cancer diagnosis (current or previous), and living in Sweden, completed an online survey involving standardized measures of cancer-related pain (intensity and impairment), depression, fatigue, PF and social stigma.

RESULTS

Moderate to strong correlations were found between PF and all variables. In regression analyses, PF, and particularly pain acceptance, accounted for a large and significant proportion of the observed variance in depression, pain-related and overall functioning, after controlling for cancer status, pain intensity and social stigma.

CONCLUSION

Consistent with studies of non-cancer-related pain, higher levels of PF were strongly associated with lower levels of distress and better functioning in individuals with cancer-related pain. Further studies are needed to further explore these relationships and to determine whether psychosocial treatments targeting PF may be of benefit to people with chronic cancer-related pain.

SIGNIFICANCE

This study explores the relationship between cancer-related pain (intensity and impairment), depression, fatigue, overall functioning, social stigma and PF. The findings suggest that higher levels of PF are associated with lower levels of distress and improved functioning in chronic cancer-related pain, after controlling for cancer status (current, in remission), pain intensity and social stigma.

Stigmatized experience is associated with exacerbated pain perception in depressed patients

Patients with depression not only have to cope with depressive and physical symptoms but also face stigmatization due to mental illness. Pain is a clinical symptom of many patients with depression. However, it is unclear whether stigmatized experience associated with mental illness directly affects depressed patients' pain perception. Here, using the event reflection task, Study 1 (N = 95) examined whether stigmatized experiences due to depression would affect patients' self-reported pain assessment. Study 2 (N = 43) further employed thermal stimuli at different intensities to examine whether stigmatization would affect patients' evoked pain. We found that patients with depression who experienced stigmatization based on mental illness reported higher pain catastrophizing and performed increased pain perception for noxious stimuli than those who did not. Our studies provide first-hand experimental evidence of the effect of stigmatized experiences on depressed patients' pain perception. The findings contribute insights for improving clinical treatment, suggesting that interventions should minimize stigmatization associated with mental illness to help patients maintain healthier physical and psychological states.

HIV, substance use, and intersectional stigma: Associations with mental health among persons living with HIV who inject drugs in Russia

HIV stigma is associated with negative physical and mental health outcomes. Intersectional stigma among persons living with HIV (PLHIV) results from interrelated, synergistic impacts of experiencing multiple stigma forms. Its relation with mental health outcomes is still an emerging area of study in this key population. This study aimed to evaluate associations of intersectional stigma, defined as endorsing high levels of HIV and substance use stigmas, with depressive and anxiety symptoms in a cohort of 111 PLHIV who inject drugs in St. Petersburg, Russia. Over a third of participants (37%) reported experiencing intersectional stigma (i.e., both stigma scores above the median). In adjusted analysis, lower Patient Health Questionnaire depression scale (PHQ-9) scores (beta (β=-4.31, 95% CI: -7.11 - -1.51, p = 0.003) and Generalized Anxiety Disorders Scale (GAD-7) scores (β=-3.64, 95% CI: -5.57 - -1.71, p < 0.001) were associated with having low scores for both HIV and substance use stigmas. Lower PHQ-9 scores (β=-3.46, 95% CI: -5.72 - -1.19, p = 0.003) and GAD-7 scores (β=-3.06, 95% CI: -4.62 - -1.50, p < 0.001) were also associated with high stigma on either HIV or substance use stigma scales. Controlling for demographics, depressive symptoms approximately linearly increased from both forms of stigma low to experiencing either form of stigma high to experiencing intersectional stigma, while levels of anxiety symptoms were comparable among participants with both types of stigma low and one stigma high. Participants who experienced intersectional stigma reported the greatest severity of both depressive and anxiety symptoms, as compared to individuals who endorsed low stigma scores (i.e., low stigma on both HIV and substance use stigma scales) or high scores of only one form of stigma. This suggests that intersectional stigma in this population of PLHIV who inject drugs in Russia is linked with worsened mental health outcomes, exceeding the effects of experiencing one form of stigma alone. Interventions to help people cope with intersectional stigma need to consider affective symptoms and tailor coping strategies to address impacts of multiple forms of mental health distress.

Genome-wide DNA methylation study identifies significant epigenomic changes associated with internalized stigma in adults with non-specific chronic low back pain

Non-specific chronic low back pain (cLBP) represents a common musculoskeletal condition with no identifiable cause. It cannot be diagnosed with conventional neuroimaging techniques such as computerized tomography (CT). The diagnostic uncertainty that characterizes non-specific cLBP can lead to stigmatizing responses from others that can become internalized Among individuals with non-specific cLBP, internalized stigma is associated with greater pain intensity and disability. Yet, no study has examined the biological mechanism linking high internalized stigma to worse outcomes in individuals with non-specific cLBP. We aimed to identify differentially methylated loci (DML), enrichment pathways, and associated network interactions among individuals with non-specific cLBP experiencing low vs. high internalized stigma. We examined DNA methylation in whole blood samples from 48 adults, ages 19-85, using reduced representation bisulfite sequencing (RRBS). After controlling for age, sex, race, and multiple testing, differentially methylated loci (DML) differed in adults with low vs. high internalized stigma by at least 10% and q < 0.01 in 3,665 CpG sites: 2,280 hypomethylated and 1,385 hypermethylated. Gene ontology (GO) analyses of the annotated genes from these sites revealed significant enrichment of 274 biological processes, 29 cellular components, and 24 molecular functions (adjusted p < 0.05). The top enriched molecular functions regulate protein binding and DNA binding of transcription factor activity. Pathway analyses indicated that many functional genomic pathways, including Hippo Signaling, Melanogenesis, and Pathways in Cancer, were enriched with differentially methylated genes. Also, there was a significant interaction between relevance pathways such as P53, mTOR, PI3K-Akt, and Wnt signaling pathways. These pathways have previously been associated with neuroinflammation, neurodegeneration, and stress-related conditions. Thus, findings point to possible stress-induced DNAm changes as the link between high levels of internalized stigma and worse outcomes in adults with non-specific cLBP.

Frameworks and measures for HIV-related internalized stigma, stigma and discrimination in healthcare and in laws and policies: a systematic review

Introduction

There is strong global commitment to eliminate HIV‐related stigma, and work in this area continues to evolve. Wide variation exists in frameworks and measures used.

Methods

Building on the existing knowledge syntheses, we carried out a systematic review to identify frameworks and measures aiming to understand or assess internalized stigma, stigma and discrimination in healthcare, and in law and policy. The review addressed two questions: Which conceptual frameworks have been proposed to assess internalized stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? Which measures of these different types of stigma and discrimination have been proposed and what are their descriptive properties? Searches, completed on 6 May 2021, cover publications from 2008 onwards. The review is registered in PROSPERO (CRD42021249348), the protocol incorporated stakeholder input, and the data are available in the Systematic Review Data Repository.

Results and discussion

Sixty‐nine frameworks and 50 measures met the inclusion criteria. Critical appraisal figures and detailed evidence tables summarize these resources. We established a compendium of frameworks and a catalogue of measures of HIV‐related stigma and discrimination. Seventeen frameworks and 10 measures addressed at least two of our focus domains, with least attention to stigma and discrimination in law and policy. The lack of common definitions and variability in scope and structure of HIV‐related frameworks and measures creates challenges in understanding what is being addressed and measured, both in relation to stigma and efforts to mitigate or reduce its harmful effects. Having comparable data is essential for tracking change over time within and between interventions.

Conclusions

This systematic review provides an evidence base of current understandings of HIV‐related stigma and discrimination and how further conceptual clarification and increased adaptation of existing tools might help overcome challenges across the HIV care continuum. With people living with HIV at the centre, experts from different stakeholder groups could usefully collaborate to guide a more streamlined approach for the field. This can help to achieve global targets and understand, measure and help mitigate the impact of different types of HIV‐related stigma on people's health and quality of life.

HIV-Related Intersectional Stigma and Discrimination Measurement: State of the Science

Background. Across settings, individuals from populations that are multiply stigmatized are at increased risk of HIV and experience worse HIV treatment outcomes. As evidence expands on how intersecting stigmatized identities and conditions influence HIV outcomes, researchers have used diverse quantitative approaches to measure HIV-related intersectional stigma and discrimination. To date, no clear consensus exists regarding how to best quantitatively measure and analyze intersectional stigma and discrimination. Objectives. To review and document existing quantitative measures of HIV-related intersectional stigma and discrimination to inform research, programmatic, and policy efforts. Search Methods. We searched 5 electronic databases for relevant studies. References of included articles were screened for possible inclusion. Additional articles were screened on the basis of consultations with experts in the field. Selection Criteria. We included peer-reviewed studies published between January 1, 2010, and May 12, 2021, that were HIV related and presented 1 or more quantitative measures of stigma and discrimination using an intersectional lens in measure design or analysis. Data Collection and Analysis. Systematic methods were used to screen citations and abstract data via a standardized coding form. Data were analyzed by coding categories stratified according to 2 subgroups: (1) studies incorporating a single intersectional measure and (2) studies that examined intersectional stigma through analytical approaches combining multiple measures. Main Results. Sixteen articles met the inclusion criteria, 7 of which explicitly referenced intersectionality. Ten studies were from the United States. All of the studies included participants living with HIV. Among the 4 studies incorporating a single intersectional stigma measure, 3 explored race and gender stigma and 1 explored gender and HIV stigma. Studies involving analytic approaches (n = 12) mostly examined intersectional stigma via interaction terms in multivariate regression models. Three studies employed structural equation modeling to examine interactive effects or latent constructs of intersectional stigma. Conclusions. Research on the measurement of HIV-related intersectional stigma and discrimination is currently concentrated in high-income settings and generally focuses on the intersection of 2 identities (e.g., race and gender). Efforts are needed to expand appropriate application of intersectionality in the development, adaptation, and use of measures of HIV-related intersectional stigma and discrimination. The use of context-, identity-, or condition-adaptable measures should be considered. Researchers should also carefully consider how to meaningfully engage communities in the process of measurement development. Public Health Implications. The measures and analytic approaches presented could significantly enhance public health efforts in assessing the impact of HIV-related intersectional stigma and discrimination on critical health outcomes. (Am J Public Health. 2022;112(S4):S420-S432. https://doi.org/10.2105/AJPH.2021.306639).

Finding the Right Angle: A Geometric Approach to Measuring Intersectional HIV Stigma

Intersectionality has emerged as theoretically and practically important to advancing HIV stigma research. However, few psychometric measures capture the intricacies of intersectional stigma. Grounded in the HIV stigma framework and contemporary theories of intersectionality, this paper describes a novel approach to conceptualizing the measurement of intersectional stigma. Taking the notion of an intersection literally, that is the point at which two or more lines meet and form a union, we offer a geometric conceptualization for developing a psychometric instrument to measure intersectional stigma. Ratings of stigmatized attributes, such as stigma ascribed to gender, race, sexual orientation, and HIV status are assessed on independent scales to calculate their intersection using the Pythagorean Theorem, c = [Formula: see text] (a² + b²) and its extension to multiple stigmatized attributes d = [Formula: see text] (a² + b² + c²). Data from a sample of Black /African American women living with HIV were used to test the concept of a geometric approach to measuring intersectional enacted stigma and intersectional anticipated stigma. Findings from the test of concept were encouraging and warrant further scale development research.

Global Systematic Review of Common Mental Health Disorders in Adults Living with HIV

PURPOSE OF THE REVIEW

By reviewing the most recent common mental health disorders (CMHD) studies in people living with HIV (PLWH) (2018-2020), this review discusses the prevalence of CMHD, factors associated with CMHD in PLWH, mental health in PLWH from vulnerable groups, the impact of CMHD on HIV disease progression and adherence to antiretroviral therapy and the efficacy of different treatment approaches.

RECENT FINDINGS

After screening for eligibility 142 studies were included in the final systematic review. Only 27% of studies were conducted in Sub-Saharan Africa, which carries the highest burn of HIV disease globally. Despite the well-established increased risk of CMHD in PLWH, the current prevalence remains high, with studies reporting 28%-62% of PLWH having mental health symptoms.

CONCLUSION

Despite the significant challenges that CMHDs present to successful HIV treatment, there are many mental health treatments and interventions which can improve outcomes in PLWH and opportunities to task-shift and integrate mental health care with HIV care.

Internalized stigma, depressive symptoms, and the modifying role of antiretroviral therapy: A cohort study in rural Uganda

Depression affects over 40% of people with HIV (PHIV) in low- and middle-income countries, and over half of PHIV report HIV-related internalized stigma. However, few longitudinal studies of PHIV have examined the relationship between HIV-related stigma and depression. Data were analyzed from the 2007–15 Uganda AIDS Rural Treatment Outcomes (UARTO) Study, a cohort of 454 antiretroviral therapy (ART)-naïve PHIV (68% women) starting ART. Our primary outcome was depression symptom severity over the first two years of ART, measured using a locally adapted version of the Hopkins Symptom Checklist; our primary exposure was the 6-item Internalized AIDS-Related Stigma Scale. Both scores were measured at enrollment and at quarterly follow-up visits. We fit linear generalized estimating equations (GEE) regression models to estimate the association between stigma and depression symptom severity, adjusting for potential confounders. We included a stigma×time product term to assess the modifying effect of ART on the association between internalized stigma and depression symptom severity. UARTO participants had a median age of 32 years and median enrollment CD4 count of 217 cells/mm³. Both depression symptom severity and internalized stigma declined on ART, particularly during the first treatment year. In multivariable regression models, depression symptom severity was positively associated with internalized stigma (b=0.03; 95% confidence interval [CI], 0.02 to 0.04) and negatively associated with ART duration >6 months (b =− 0.16; 95% CI,− 0.19 to −0.13). The estimated product term coefficient was negative and statistically significant (P = 0.004), suggesting that the association between internalized stigma and depression symptom severity weakened over time on ART. Thus, in this large cohort of PHIV initiating ART in rural Uganda, depression symptom severity was associated with internalized stigma but the association declined with time on ART. These findings underscore the potential value of ART as a stigma reduction intervention for PHIV, particularly during early treatment.

Sexual History Taking: An Opportunity to Reduce Health Disparities

ABSTRACT

Sexual history taking is an important part of caring for any clinical population. However, the topic is often wrapped in discomfort that makes it more challenging than it needs to be for both the provider and the individual providing the history. The act of taking an effective sexual history is more than simply asking all the right questions in the right ways; it requires an awareness of the impact of the clinical environment, the provider's own comfort with the content, and an awareness of any personal biases. In this study, we provide a framework for evaluating and addressing many of these factors as well as providing key points for consideration as a health care provider of any level. We offer several concrete strategies for including these strategies and processes in multiple clinical environments.

A scoping review of the integration of empowerment-based perspectives in quantitative intersectional stigma research

The genesis of the concept of intersectionality was a call to dismantle interlocking systems of oppression - racial, sexual, heterosexual, and class-based - in order to realise liberation of Black women and other women of colour. Intersectionality holds the radical potential to amplify collective efficacy, community solidarity, and liberation. The extension of intersectionality into stigma research has resulted in an increased focus on intersectional stigma in quantitative research. This raises questions regarding how the radical and liberatory potential of intersectionality is applied in stigma research. Specifically, empowerment-based perspectives may be overlooked in quantitative intersectional stigma research. We conducted a scoping review to document if and how empowerment-based perspectives were included in intersectional stigma quantitative studies. We identified and included 32 studies in this review that examined varied stigmas, most commonly related to race, gender, HIV and sexual orientation. In total 13/32 (40.6%) of these studies reported on empowerment-based factors; most of these examined social support and/or resilience. Taken together, findings suggest that the quantitative intersectional stigma research field would benefit from expansion of concepts studied to include activism and solidarity, as well as methodological approaches to identify the protective roles of empowerment-based factors to inform health and social justice-related programmes and policy.

People living with HIV and the emerging field of chronic pain-what is known about epidemiology, etiology, and management

PURPOSE OF REVIEW

Chronic pain is common in people living with HIV (PLWH). It causes significant disability and poor HIV outcomes. Despite this, little is understood about its etiology and management.

RECENT FINDINGS

Recent studies suggest that chronic pain in PLWH is caused by inflammation that persists despite viral load suppression. This coupled with central sensitization and psychosocial factors leads to chronic pain that is difficult to manage. PLWH with chronic pain often feel that their pain is incompletely treated, and yet there are few evidence-based options for the management of chronic pain in PLWH. Recent studies suggest that an approach pairing pharmacotherapy and nonpharmacologic therapy may address the complex nature of chronic in PLWH. Chronic pain in PLWH is common yet poorly understood. Further research is needed in order to better understand the etiology of chronic pain and its optimal management.

“I have failed to separate my HIV from this pain”: the challenge of managing chronic pain among people with HIV

Pain is a highly prevalent and burdensome symptom among people with HIV (PWH). This study aims to identify how the experience of living with HIV and chronic pain influences pain beliefs, health-seeking and pain management. Thirty-nine purposively sampled PWH with chronic pain (sample characteristics = 61% women, 79% Black, Asian and minority ethnic groups, 18% men who have sex with men, 45-54 median age category) participated in focus groups in London. Focus groups were co-facilitated with community members. Transcripts wereanalysed using a thematic approach. Findings revealed that HIV stigma, fractured care pathways, and general practitioners' lack of HIV training are barriers to supported pain management. Unaddressed pain results in poorer mental health and reduced quality of life, which has important clinical implications for HIV treatment adherence. Creating HIV-specific pain resources, activating social networks, and pain self-management techniques are potential solutions. Person-centred assessment and HIV training is needed to help clinicians identify PWH with chronic pain. Clear guidelines need to be developed to identify which health service providers are responsible for chronic pain management in PWH. This study generated a refined version of the Fear Avoidance Model that introduces a dimension of HIV-specific behaviours that impact PWHs seeking chronic pain management.

Internalized HIV Stigma and Pain among Women with HIV in the United States: The Mediating Role of Depressive Symptoms

Pain is common in women with HIV, though little research has focused on psychosocial experiences contributing to pain in this population. In the present study we examined whether internalized HIV stigma predicts pain, and whether depressive symptoms mediate this relationship among women with HIV. Data were drawn from the Women's Interagency HIV Study (WIHS), for 1,364 women with HIV who completed three study visits between 2015 and 2016. We used a sequential longitudinal design to assess the relationship between internalized HIV stigma at time 1 on pain at time 3 through depressive symptoms at time 2. Analyses revealed internalized HIV stigma was prospectively associated with greater pain, B = 5.30, 95% CI [2.84, 7.60]. The indirect effect through depressive symptoms supported mediation, B = 3.68, 95% CI [2.69, 4.79]. Depression is a modifiable risk factor that can be addressed to improve pain prevention and intervention for women with HIV.

Intersectionality and health-related stigma: insights from experiences of people living with stigmatized health conditions in Indonesia

Background

Health-related stigma is a complex phenomenon, the experience of which intersects with those of other adversities arising from a diversity of social inequalities and oppressive identities like gender, sexuality, and poverty – a concept called “intersectionality”. Understanding this intersectionality between health-related stigma and other forms of social marginalization can provide a fuller and more comprehensive picture of stigma associated with health conditions. The main objective of this paper is to build upon the concept of intersectionality in health-related stigma by exploring the convergence of experiences of stigma and other adversities across the intersections of health and other forms of social oppressions among people living with stigmatized health conditions in Indonesia.

Methods

This qualitative study interviewed 40 people affected by either of four stigmatizing health conditions (HIV, leprosy, schizophrenia, and diabetes) in Jakarta and West Java, Indonesia between March and June 2018. Data was analyzed thematically using an integrative inductive-deductive framework approach.

Results

The main intersectional inequalities identified by the participants were gender and socioeconomic status (n = 21), followed by religion (n = 13), age (n = 11), co-morbidity (n = 9), disability (n = 6), and sexuality (n = 4). Based on these inequalities/identities, the participants reported of experiencing oppression because of prevailing social norms, systems, and policies (macro-level), exclusion and discrimination from societal actors (meso-level), and self-shame and stigma (micro-level). While religion and age posed adversities that negatively affected participants in macro and meso levels, they helped mitigate the negative experiences of stigma in micro level by improving self-acceptance and self-confidence.

Conclusion

This study uncovered how the experience of health-related stigma intersects with other oppressions originating from the various social inequalities in an individual’s life. The findings highlight the importance of acknowledging and understanding the multi-dimensional aspect of lives of people living with stigmatized health conditions, and warrant integrated multi-level and cross-cutting stigma reduction interventions to address the intersectional oppressions they experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01318-w.

Comprehensive Geriatric Assessment in Older Persons With HIV

With increased longevity related to the advent of antiretroviral therapy, there are increasing proportions of older persons with HIV (PWH). Prior studies have demonstrated increased prevalence of geriatric syndromes in older PWH and recommended the Comprehensive Geriatric Assessment (CGA) in this population. However, there is currently no peer-reviewed literature that outlines how to perform the CGA in PWH in the clinical setting. In this article, we offer a review on how to perform the CGA in PWH, outline domains of the CGA and their importance in PWH, and describe screening tools for each domain focusing on tools that have been validated in PWH, are easy to administer, and/or are already commonly used in the field of geriatrics.

Peer-led Self-management Interventions and Adherence to Antiretroviral Therapy Among People Living with HIV: A Systematic Review

Adherence to antiretroviral therapy (ART) is essential to reduce morbidity and mortality among people living with HIV (PLWH). However, adherence remains suboptimal, and PLWH may benefit from more self-management support to address the complexities of chronic illness. Our objective was to identify the impact of peer-led self-management interventions on adherence and patient-reported outcomes (PROs) among PLWH. We searched MEDLINE, PubMed, Embase, PsycINFO, and CINAHL for English language publications from 1996 to March 2018, and included controlled intervention studies. Additional articles were handsearched, risk of bias assessed, and narrative syntheses outlined. Thirteen studies met inclusion criteria. Findings demonstrate unclear effectiveness for peer-led self-management interventions improving ART adherence; however evidence was limited with only seven studies measuring this outcome and some risk of bias. Many PROs were measured, with limited consistent findings. Future research is needed to strengthen the evidence regarding effects of peer-led self-management interventions on adherence and PROs among PLWH.

The effect of concomitant fibromyalgia in HIV infected patients receiving antiretroviral therapy: a prospective cross-sectional study

Background

HIV infected patients receiving antiretroviral therapy (ART) have extensive musculoskeletal system involvement. Arthralgia and myalgia are the most common forms. Fibromyalgia Syndrome (FMS) is a chronic pain syndrome of the musculoskeletal system characterized by diffuse pain including arthralgia and myalgia. These overlapping symptoms are suggested the relationship between HIV and FMS. The primary purpose of this study was to determine the prevalence of FMS in HIV/AIDS patients. The secondary objective was to investigate the effects of FMS on functional status, depression, fatigue, sleep pattern and quality of life.

Methods

A total of 225 HIV infected patients who were receiving ART were included in this cross-sectional prospective study. The demographic data of the participants, CD4 T-lymphocyte count (cells/mm³), viral load (> 40 copy/ml), and ART regimens were recorded. FMS diagnosis was based on 2016 revision of diagnostic criteria. All patients completed the following questionnaires: Fibromyalgia Impact Questionnaire (FIQ), Beck Depression Inventory (BDI), Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), and SF-36 scale.

Results

FMS was found in 20% of the HIV infected patients (n = 45). The mean duration of disease was 4.74 ± 4.42 years; it was significantly longer in patients with FMS (p = 0.007). The median CD4 T-lymphocyte count was found to be 616.00 ± 303.91 cells/mm³, and it was significantly higher in patients without FMS (p = 0.06). No statistically significant difference was found between the two groups according to the drug regimens used. A statistically significant difference was found in FIQ, BDI, PSQI, FSS and all subgroups of the SF-36 scale between the patients with and without FMS (p = 0.001).

Conclusions

A slightly higher frequency of FMS was determined in HIV infected patients receiving ART compared to previous studies. It was shown that presence of FMS negatively affected the function, depression, fatigue, sleep, and quality of life. Detection of FMS may decrease depression, fatigue, and sleep disorders and increase the quality of life in HIV infected patients. FMS should be distinguished correctly for an accurate treatment management of HIV and for increasing ART compliance.

Assessment of pain and associated factors in people living with HIV/AIDS

OBJECTIVE

to evaluate pain in people living with human immunodeficiency virus/acquired immunodeficiency syndrome and to relate it to sociodemographic and clinical factors, depressive symptoms and health-related quality of life.

METHOD

descriptive, analytical, observational, cross-sectional and quantitative study. Three hundred and two (302) people assisted at a specialized care service participated in the study. Instruments were used to evaluate sociodemographic and clinical data, depressive symptoms, and health-related quality of life. Descriptive, bivariate analysis and multiple logistic regression were used.

RESULTS

the incidence of pain of mild intensity was 59.27%, recurrent in the head, with interference in mood, mostly affecting females and individuals with no schooling/low schooling. Women were more likely to have moderate or severe pain. People aged 49 to 59 years had greater pain intensity than people aged 18 to 29 years. The variables depressive symptoms and pain were directly proportional. The higher the health-related quality of life and schooling, the lower was the possibility of presence of pain.

CONCLUSION

presence of pain is of concern and has association with female sex, lack of schooling/low schooling, worse level of health-related quality of life and presence of depressive symptoms.

Social support buffers the negative influence of perceived injustice on pain interference in people living with HIV and chronic pain

Introduction:

A growing literature attests to the overwhelming prevalence of disabling chronic pain among people living with HIV (PLWH), yet very little is known about psychosocial contributors to poor chronic pain outcomes in this population. Pain-related perception of injustice may promote pain interference by hindering engagement in daily activities among individuals with chronic pain. Social support has been shown to buffer the negative impact of harmful beliefs on well-being and facilitate adjustment to chronic pain.

Objective:

This cross-sectional study tested the buffering hypothesis of social support to determine whether increasing levels of social support mitigate the negative influence of perceived injustice on pain interference.

Methods:

A total of 60 PLWH with chronic pain completed measures of perceived injustice, social support, pain severity, and interference, as well as depressive symptoms.

Results:

In a regression-based model adjusted for age, sex, depressive symptoms, and pain severity, results indicated that social support significantly moderated (ie, buffered) the association between perceived injustice and pain interference (P = 0.028). Specifically, it was found that perceived injustice was significantly associated with greater pain interference among PLWH with low levels of social support (P = 0.047), but not those with intermediate (P = 0.422) or high levels of social support (P = 0.381).

Conclusion:

Pain-related injustice perception reflects harmful beliefs regarding severity of loss consequent to chronic pain development, a sense of unfairness, and irreparability of loss. Access to a social support network may provide an adaptive means of mitigating the negative effects of perceived injustice.

A preliminary analysis of the association between perceived stigma and HIV-related pain in South Africans living with HIV

Background

Stigma related to the human immunodeficiency virus (HIV) remains common and has been associated with severity of HIV-related symptoms. Associations between HIV stigma and HIV-related pain, one of the most common symptoms in HIV, have however not been investigated. Data from low back pain populations suggest that stigma is associated with worse pain intensity and so we hypothesised that the same would be the case in HIV.

Aim

The goal of this study was to assess the association between HIV stigma and pain intensity in people living with HIV (PLWH) with chronic pain whilst controlling for depression, a well-established correlate of pain.

Setting

The study took place at an HIV clinic in Johannesburg, South Africa.

Methods

Mediation analysis was used to assess the effect of depression on the relationship between stigma and pain intensity in a cross-sectional cohort of 50 PLWH and chronic pain (pain most days of the week for > 3 months). All participants were assessed using the HIV/AIDS Stigma Instrument – PLWA, an 11-point numerical pain rating scale and the Beck Depression Inventory II.

Results

In all, 88% (44/50) of participants reported experiencing some form of HIV stigma (HIV stigma scale score ≥ 1). Worst pain intensity and depressive symptoms individually correlated with total stigma score (Spearman’s r = 0.33, p = 0.02 for both). The mediation analysis highlighted that mediation of the relationship by depression was equivocal (b = -0.002, bootstrapped confidence interval -0.02 to 0.00).

Conclusion

Whilst these preliminary data are marginal, they do suggest that associations between HIV stigma and HIV-related pain warrant further investigation. Future study should also include potential mechanisms, which may include mediation through depression.