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HIV-Related Stigma and Viral Suppression Among African-American Women: Exploring the Mediating Roles of Depression and ART Nonadherence

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Abstract

We used baseline data from a sample of African-American women living with HIV who were recruited to participate in a stigma-reduction intervention in Chicago and Birmingham (2013–2015) to (1) evaluate the relationship between HIV-related stigma and viral suppression, and (2) assess the role of depression and nonadherence to antiretroviral therapy (ART) as mediators. Data from women were included in this secondary analysis if they were on ART, had viral load data collected within 8-weeks of study entry and had complete covariate data. We used logistic regression to estimate the total effect of HIV-related stigma (14-item Stigma Scale for Chronic Illness) on viral suppression (< 200 copies/mL), and serial mediation analysis to estimate indirect effects mediated by depressive symptoms (8-item Patient Health Questionnaire) and ART nonadherence (number of days with missed doses). Among 100 women who met study inclusion criteria, 95% reported some level of HIV-related stigma. In adjusted models, higher levels of HIV-related stigma were associated with lower odds of being virally suppressed (AOR = 0.93, 95% CI = 0.89–0.98). In mediation analysis, indirect effects through depression and ART nonadherence were not significant. Findings suggest that HIV-related stigma is common among African-American women living with HIV, and those who experience higher levels of stigma are less likely to be virally suppressed. However, the mechanisms remain unclear.

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Acknowledgements

This study was made possible by funding from NIMH grant R01-MH98675 (PI: Rao) with additional support from Ms. Lipira’s AHRQ Health Services Training Award (T32 HS013853-13) and Dr. Williams’s VA Health Services Research & Development Career Development Award (CDA 12-276). The authors would also like to extend a special thank you to the women who participated in the Unity Study.

Funding

This study was made possible by funding from NIMH grant R01-MH98675 (PI: Rao) with additional support from Ms. Lipira’s AHRQ Health Services Training Award (T32 HS013853-13) and Dr. Williams’s VA Health Services Research & Development Career Development Award (CDA 12-276).

Author information

Authors and Affiliations

  1. Department of Health Services, University of Washington, Seattle, WA, USA

    Lauren Lipira, Emily C. Williams & Joseph M. Unger

  2. VA Puget Sound Health Care System, Seattle, WA, USA

    Emily C. Williams & Preston Greene

  3. School of Social Work, University of Washington, Seattle, WA, USA

    David Huh

  4. Department of Global Health, University of Washington, Seattle, WA, USA

    Christopher G. Kemp, Paul E. Nevin, Michele P. Andrasik & Deepa Rao

  5. Fred Hutch, Seattle, WA, USA

    Joseph M. Unger & Michele P. Andrasik

  6. Department of Biostatistics, University of Washington, Seattle, WA, USA

    Patrick Heagerty

  7. Stroger Hospital of Cook County and Ruth M. Rothstein CORE Center, Chicago, IL, USA

    Audrey L. French

  8. Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Susan E. Cohn

  9. Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, USA

    Janet M. Turan

  10. Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA

    Michael J. Mugavero

  11. Department of Psychology, University of Washington, Seattle, WA, USA

    Jane M. Simoni

  12. Department of Health Services, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA, 98195-7660, USA

    Lauren Lipira

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  1. Lauren Lipira
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Correspondence to Lauren Lipira.

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Conflict of interest

The authors declare no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Informed consent was obtained from all individual participants included in the study.

Appendices

Appendix 1: Baseline Characteristics of African-American Women Living with HIV Who Participated in a Trial of an HIV-Related Stigma-Reduction Intervention, Comparing Those Who Had Viral Loads Collected Within 8-Weeks of Study Entry (Primary Sample) to Those Who Had Viral Loads Collected Within 24-Weeks of Study Entry (Sensitivity Sample)

 

Primary sample (8-week viral load) (N = 100)

Sensitivity sample (24-week viral load) (N = 184)

Median/N

IQR/ %

Median/N

IQR/ %

Site

 NU

26

26%

374

19%

 CORE

31

31%

65

35%

 UAB

43

43%

85

46%

Age (years)

45 years

38–53

46 years

39–54

Time living with HIV (years)

14 years

9–20

14 years

8–20

Education

 Less than HS

39

39%

68

37%

 HS or equivalent

18

18%

41

22%

 College

32

32%

59

32%

 More than college

11

11%

16

9%

Alcohol use severity (AUDIT-C score)

 0

46

46%

81

44%

 1–2

30

30%

63

34%

 3–7

21

21%

36

20%

 8–12

3

3%

4

2%

HIV-related stigma (SSCI)

31

23–41

30

22–41

Depressive symptom severity (PHQ-8)

7

3–13

6

2–12

ART nonadherence (out of 30 days)

1

0–2

1

0–2

Viral suppression

 Yes

79

79%

156

78%

 No

21

21%

44

22%

  1. NU Northwestern University, CORE Ruth M. Rothstein CORE Center, UAB University of Alabama, Birmingham, IQR interquartile range, AUDIT-C Alcohol Use Disorders Identification Test—Consumption, SSCI 14-item Stigma Scale for Chronic Illness, PHQ-8 8-item Patient Health Questionnaire, ART antiretroviral therapy

Appendix 2: Sensitivity Analysis Comparing Direct And Indirect Effects of HIV-Related Stigma on Viral Suppression Among Two Samples of African-American Women Living with HIV Enrolled in the Unity Study, Differing by Viral Load Collection Period

 

Primary sample (8-week viral load) (N = 100)

Sensitivity sample (24-week viral load) (N = 184)

β

95% CI

β

95% CI

Primary model a

Total effect (difference in log-odds)

− 0.069

− 0.117 to − 0.021

− 0.052

− 0.084 to − 0.020

Direct effect

− 0.085

− 0.145 to − 0.025

− 0.043

− 0.082 to − 0.004

Indirect effects

 Stigma > depression > nonadherence > viral suppression

− 0.006

− 0.045 to 0.029

− 0.003

− 0.010 to 0.002

 Stigma > depression > viral suppression

0.010

− 0.046 to 0.054

0.010

− 0.037 to 0.014

 Stigma > nonadherence > viral suppression

0.002

− 0.087 to 0.051

0.001

− 0.012 to 0.010

Secondary model b

Total effect (difference in log-odds)

− 0.096

− 0.016 to − 0.032

− 0.056

− 0.089 to − 0.022

Direct effect

− 0.238

− 0.385 to − 0.091

− 0.052

− 0.092 to − 0.011

Indirect effects

 Stigma > depression > nonadherence > viral suppression

− 0.010

− 0.072 to 0.054

− 0.002

− 0.011 to 0.003

 Stigma > depression > viral suppression

0.064

− 0.140 to 0.206

0.006

− 0.034 to 0.021

 Stigma > nonadherence > viral suppression

0.009

− 0.105 to 0.107`

0.001

− 0.012 to 0.011

  1. aAdjusted for treatment, site, age, education, time living with HIV
  2. bAdjusted for treatment, site, age, education, time living with HIV, alcohol use severity

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Lipira, L., Williams, E.C., Huh, D. et al. HIV-Related Stigma and Viral Suppression Among African-American Women: Exploring the Mediating Roles of Depression and ART Nonadherence. AIDS Behav 23, 2025–2036 (2019). https://doi.org/10.1007/s10461-018-2301-4

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