HIV-related stigma and non-adherence to antiretroviral medications among people living with HIV in a rural setting

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Highlights

  • People with HIV experience cumulative stigma with effects contributing to stress.

  • Family distancing and discrimination impact the health of people with HIV.

  • Effects of alcohol use on medication adherence are independent of HIV-stigma.

  • Cumulative HIV stigma impacts HIV treatment adherence through HIV-related stress.

Introduction

Combination antiretroviral therapies (ART) suppress HIV replication and improve the health and longevity of people living with HIV (Taylor et al., 2019). The success of ART hinges on persistent adherence, with even the most forgiving ART regimens requiring greater than 80% adherence to minimize the risks of virologic failure (Martin et al., 2008; Byrd et al., 2019). Maintaining optimal ART adherence, however, remains a significant challenge for many people living with HIV, with as many as half of people living with HIV in the United States having unsuppressed HIV, the poorest rate of viral suppression among high-income countries (Kaiser Family Foundation, 2019). A recent meta-analysis found that one in four people who experience challenges to remaining adherent to ART attribute their poor adherence to emotional distress and another one in four attribute their nonadherence to alcohol and other substance misuse (Shubber et al., 2016). Alcohol use is a common correlate of stress and both alcohol use and stress predict ART nonadherence and unsuppressed HIV (Algur et al., 2018).

Stigma experiences are a common source of stress for people living with HIV and stigma itself is also known to challenge ART adherence (Turan et al., 2017). Stigma is the social devaluation and discrediting associated with specific characteristics, attributes, and behaviors (Goffman, 1963), and stigma is widely regarded as a complex social phenomenon (Mahajan et al., 2008; Blake Helms et al., 2017). Since the beginning of the HIV epidemic, stigma has undermined treatment efforts (Sengupta et al., 2011; Stangl et al., 2013; van der Straten et al., 1998; Fife and Wright, 2000; Berger et al., 2001). Stigma impacts the health of people living with HIV through multiple mechanisms including interpersonal relations, psychological resources, mental health and stress (Turan et al., 2014; Bauer, 2014). Both salient (e.g., discrimination) and subtle (e.g., microaggressions) stigma experiences are potent barriers to seeking health services and adhering to treatment regimens (Eaton et al., 2018; Friedman et al., 2018a, 2018b). Stigma experiences vary across social contexts. For example, stigma occurs to a greater degree in rural areas relative to urban centers (Gonzalez et al., 2009; Kalichman et al., 2017). A study of HIV stigma experiences in the southeastern US found that lower population density is associated with greater HIV stigma over and above several known predictors of ART adherence including age, education, years since testing HIV positive, and depression symptoms (Kalichman et al., 2017). Furthermore, behaviors aimed to avoid stigma by concealing HIV status, such as avoiding clinic visits and hiding medications, create barriers to care and ART adherence (Kalichman et al., 2017). HIV-related enacted stigma, specifically social exchanges that people experience as stigma, are therefore among the most robust barriers to engaging in HIV care and adhering to ART (Sweeney and Vanable, 2016). Despite decades of stigma research, there are few empirically tested mechanisms to explain how stigma impedes ART adherence.

One potential mechanism by which stigma may impact adherence is stress (Evangeli and Wroe, 2017; Rueda et al., 2016), which in turn can trigger alcohol use as a means of coping, with alcohol use further diminishing adherence (Kalichman and Grebler, 2010). Alcohol use is associated with both stress experiences and ART nonadherence (Algur et al., 2018), and alcohol use mediates the association between emotional distress and ART adherence (Hill et al., 2019). Katz et al. (2013) developed a framework for explaining the impact of enacted stigma on ART adherence. In this model, stigma operates by compromising general psychological processes, particularly impaired coping in response to stress.

The current study extends the framework offered by Katz et al. (2013) to examine the association between HIV-related stigma experiences and ART adherence. We specifically tested a serial mediation model, a sequential chain of direct and indirect effects of stigma on ART adherence, to test whether stress and alcohol use explain the effects of stigma on adherence. Our aim was to test a conceptual model grounded in past studies linking stigma to stress, stress to alcohol use, and all three factors to ART adherence. Our study used prospectively collected data to assess cumulative stigma experiences over the course of a year in predicting objectively measured ART adherence. We assessed HIV-related stress as it may co-occur over time with stigma experiences and alcohol use. We tested the hypothesis that the accumulation of HIV stigma experienced over a 12-month period would predict ART adherence and that the association between stigma and adherence would be explained by HIV-related stress and alcohol use.

Section snippets

Participants and procedures

Men (n = 175) and women (n = 76) were recruited from a publicly funded HIV clinic in central Georgia serving a small city and surrounding rural areas between September 2015 and December 2017. Participants were referred by clinic staff if they were returning to care after having fallen out of care for at least 6-months or were identified by a provider as either having unsuppressed HIV or at risk for unsuppressed HIV.

During a scheduled office visit, clinic patients were referred to the study and

Results

The sample included 104 (45%) patients who had fallen out of HIV care and were returning for services, 45 (20%) patients who were newly diagnosed with HIV and were therefore new to HIV care, 69 (30%) patients referred by their physician or nurse due to viral rebound or non-adherence, and 12 (5%) patients who were previously treated by a different clinic and were new to the clinic participating in the study. The sample was predominantly male (68%) and African American (83%). Nearly half (46%) of

Discussion

The current study found 47% of people receiving care from an HIV clinic serving a small city and surrounding rural areas experienced at least one enacted stigma event over a 12-month observation period, with 30% of participants reporting one to four different stigma experiences. While measures differ across studies, the prevalence of stigma experiences in our sample are consistent with national studies of people receiving HIV care (Baugher et al., 2017; Williams et al., 2017). The cumulative

Author credit

S.K., H.K., E.B., M.H., and M.K. designed and conceptualized the study, E.B., M.H., and M.K. executed the study and oversaw all field word and data collection, management and integrity, S.K. and H.K. interpreted findings and prepared the report.

Acknowledgements

The study was approved by the University of Connecticut Institutional Review Board Protocol H14-184GDPH and all participants gave written informed consent. We appreciate the collaboration of the State of Georgia Heath Department and the Hope Center of Macon Georgia. This project was supported by National Institute of Alcohol Abuse and Alcoholism Grant R01-AA023727.

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