Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination

A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.

Pathways From HIV-Related Stigma, Racial Discrimination, and Gender Discrimination to HIV Treatment Outcomes Among Women Living With HIV in Canada: Longitudinal Cohort Findings

BACKGROUND

HIV-related stigma, gender discrimination, and racial discrimination harm mental health and hamper HIV treatment access for women living with HIV. Maladaptive coping strategies, such as substance use, can further worsen HIV treatment outcomes, whereas resilience can improve HIV outcomes. We examined resilience and depression as mediators of the relationship between multiple stigmas and HIV treatment outcomes among women living with HIV.

SETTING

Ontario, British Columbia, and Quebec, Canada.

METHODS

We conducted a longitudinal study with 3 waves at 18-month intervals. We used structural equation modeling to test the associations of multiple stigmas (HIV-related stigma, racial discrimination, and gender discrimination) or an intersectional construct of all 3 stigmas at wave 1 on self-reported HIV treatment cascade outcomes (≥95% antiretroviral treatment [ART] adherence, undetectable viral load) at wave 3. We tested depression and resilience at wave 2 as potential mediators and adjusted for sociodemographic factors.

RESULTS

There were 1422 participants at wave 1, half of whom were Black (29%) or Indigenous (20%). Most participants reported high ART adherence (74%) and viral suppression (93%). Racial discrimination was directly associated with having a detectable viral load, while intersectional stigma was directly associated with lower ART adherence. Resilience mediated associations between individual and intersectional stigmas and HIV treatment cascade outcomes, but depression did not. Racial discrimination was associated with increased resilience, while intersectional and other individual stigmas were associated with reduced resilience.

CONCLUSION

Race, gender and HIV-related stigma reduction interventions are required to address intersectional stigma among women living with HIV. Including resilience-building activities in these interventions may improve HIV treatment outcomes.

HIV-Related Stigma, Social Support, and Symptoms of Mental Health Disorders Among People with HIV Initiating HIV Care in Cameroon

HIV-related stigma has been associated with poor mental health among people with HIV (PWH). Social support is a potentially modifiable factor that may buffer negative mental health sequelae of HIV-related stigma. Little is known about the extent to which the modifying effect of social support differs across mental health disorders. Interviews were conducted with 426 PWH in Cameroon. Log binomial regression analyses were used to estimate the association between high anticipated HIV-related stigma and low social support from family or friends and symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and harmful alcohol use, separately. Anticipated HIV-related stigma was commonly endorsed with ∼80% endorsing at least 1 of 12 stigma-related concerns. In multivariable analyses, high anticipated HIV-related stigma was associated with greater prevalence of symptoms of depression {adjusted prevalence ratio (aPR) 1.6 [95% confidence interval (CI) 1.1-2.2]} and anxiety [aPR 2.0 (95% CI 1.4-2.9)]. Low social support was associated with greater prevalence of symptoms of depression [aPR 1.5 (95% CI 1.1-2.2)], anxiety [aPR 1.7 (95% CI 1.2-2.5)], and PTSD [aPR 1.6 (95% CI 1.0-2.4)]. However, social support did not meaningfully modify the relationship between HIV-related stigma and symptoms of any mental health disorders explored. Anticipated HIV-related stigma was commonly reported among this group of PWH initiating HIV care in Cameroon. Social concerns related to gossip or losing friends were of the greatest concern. Interventions focused on reducing stigma and strengthening support systems may be particularly beneficial and have the potential to improve the mental health of PWH in Cameroon.

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.