The Association of Stigma with Self-Reported Access to Medical Care and Antiretroviral Therapy Adherence in Persons Living with HIV/AIDS

Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California-Los Angeles, 911 Broxton Ave., Los Angeles, CA 90024, USA.
Journal of General Internal Medicine (Impact Factor: 3.42). 09/2009; 24(10):1101-8. DOI: 10.1007/s11606-009-1068-8
Source: PubMed

ABSTRACT The stigma of HIV-infection may profoundly affect the lives of persons living with HIV/AIDS (PLHA). However few studies have examined the association of HIV stigma with multiple components of HIV treatment and care.
To estimate the association between HIV stigma and: self-reported access to care, regular source of HIV care, and antiretroviral therapy adherence; and to test whether mental health mediates these associations.
Cross-sectional study.
202 PLHA living in Los Angeles County in 2007.
Participants completed an anonymous survey, assessing internalized HIV stigma (28-items, alpha = 0.93), self-reported access to medical care (six items, alpha = 0.75), regular source of HIV care, and antiretroviral therapy (ART) adherence.
One-third of participants reported high levels of stigma; 77% reported poor access to care; 42.5% reported suboptimal ART adherence; and 10.5% reported no regular source of HIV care. In unadjusted analysis, those reporting a high level of stigma were more likely to report poor access to care (OR = 4.97, 95% CI 2.54-9.72), regular source of HIV care (OR = 2.48, 95% CI 1.00-6.19), and ART adherence (OR = 2.45, 95% CI 1.23-4.91). In adjusted analyses, stigma was significantly associated with poor access to care (OR = 4.42, 95% CI 1.88-10.37), but not regular source of HIV care or ART adherence. Mental health mediated the relationship between stigma and ART adherence, but not poor access to care or regular source of HIV care.
The association of stigma with self-reported access to care and adherence suggests that efforts to improve these components of HIV care will require a better understanding of the possible effects of stigma and its mediators.

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Available from: David Martins, Aug 30, 2015
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    • "Our findings are consistent with a recent meta-analysis of patients with various long-term medical conditions, showing that patients’ beliefs have an important influence on medication adherence [223]. Results are also consistent with previous studies showing that substance use, depressive symptoms, and HIV stigma are associated with lower levels of adherence, and trust or satisfaction with the healthcare provider are associated with higher levels of adherence [7,8,180,224]. These results should be encouraging to HIV care providers, as they suggest several avenues for intervention that could result in improved adherence. "
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    ABSTRACT: Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence. We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression. In total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD = 0.603, P = 0.001), current substance use (SMD = −0.395, P = 0.001), concerns about ART (SMD = −0.388, P = 0.001), beliefs about the necessity/utility of ART (SMD = 0.357, P = 0.001), trust/satisfaction with the HIV care provider (SMD = 0.377, P = 0.001), depressive symptoms (SMD = −0.305, P = 0.001), stigma about HIV (SMD = −0.282, P = 0.001), and social support (SMD = 0.237, P = 0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD = −0.196, P = 0.001), daily dosing frequency (SMD = −0.193, P = 0.001), financial constraints (SMD −0.187, P = 0.001) and pill burden (SMD = −0.124, P = 0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries. These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.
    BMC Medicine 08/2014; 12(1):142. DOI:10.1186/PREACCEPT-1453408941291432 · 7.28 Impact Factor
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    • "Negative social norms that are created and maintained at a community level, such as community stigma, are likely to influence the use of HIV services by individuals [3]. For example, poor adherence to HIV treatment tends to be high among patients who think HIV is highly stigmatized in their community [1,15]. Thus, one’s endorsement of community stigma would influence her behavior and attitudes regarding the use of VCT. "
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    ABSTRACT: Some aspects of HIV-related stigma have been shown to be a barrier to HIV services uptake and adherence to antiretroviral treatment (ART). Distinguishing which domains of stigma impact HIV services uptake can enhance the efficacy and efficiency of stigma-reduction interventions. The relationships between use of voluntary counseling and testing (VCT) services and two domains of community stigma identified through factor analysis, negative labeling/devaluation and social exclusion, were investigated among 3749 female heads of household. Data were from a general household survey conducted in rural Mozambique. Multivariable logistic regression outcomes were: lifetime VCT use, past-6-months VCT use and VCT endorsement. Thirteen percent (13%) of the participants reported lifetime VCT use, 10% reported past-6-months VCT use and 63% endorsed VCT. A 25-point decrease (from 50 to 25) in the score for negative labeling and devaluation stigma was associated with increased lifetime VCT use (adjusted OR: 1.6, 95%CI: 1.1-2.3) and past-6-months VCT use (adjusted OR: 1.6, 95%CI: 1.1-2.4). A decrease from 50 to 25-points in the score for social exclusion stigma was associated with 1.5 and 1.3-fold increase in odds for past-6-months VCT use and endorsing VCT use, respectively (p < 0.001 for both). Compared with never-testers, considerably high endorsement of VCT use was observed among testers who did not receive HIV test results (adjusted OR: 2.7, 95%CI: 1.6-4.6) and much higher among testers who received results (adjusted OR: 7.3, 95%CI: 4.9-11.0). Distance from health facilities was associated with lower VCT use, but not lower endorsement of VCT. VCT use and endorsement might differ by domains of stigma held by individuals in the community. Greater uptake and favorable disposition towards use of VCT services in rural settings might be achieved by addressing stigma via domain-specific interventions and by improving the proximity of services and the dissemination of HIV test results.
    BMC Public Health 12/2013; 13(1):1155. DOI:10.1186/1471-2458-13-1155 · 2.32 Impact Factor
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    • "For instance, early research on HIV found that the inference of high-risk behaviours that led to seroconversion are often negatively evaluated, leading to less support (Bennett, 1990; Berk, 1990). Likewise, the relationship between HIV-related stigma and reduced medication adherence or contact with medical providers may also be explained in this way (Sayles et al., 2009). Specifically, despite important reductions in the number of medications required to sustain an undetectable viral load, even a single pill regimen serves as a daily reminder of one's HIV status. "
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    ABSTRACT: Abstract Objective: HIV-related stigma is a major driver of poor prognosis for the treatment and reduced spread of HIV. The present article provides a qualitative analysis surrounding various themes related to stigma and shame as a result HIV Design: Eight gay men recruited from a community HIV clinic contacted the researchers in response to a study involving participation in a structured, 8-week group intervention for HIV-related stigma. Following this group, three men took part in open-ended interviews about their thoughts and experiences. Methods: IPA (interpretative phenomenological analysis) was used to examine the participants' experiences surrounding shame and stigma related to living with HIV. Results: Three superordinate themes were identified: social support and the disclosure of serostatus, stigma associated with serosorting, and attempts to negotiate a spoiled identity. Conclusion: In San Francisco, a city with a great deal of acceptance surrounding HIV and a large, politically active community of persons living with HIV, gay men continue to struggle with disclosure and stigma. This stigma may be an unexpected result of a high degree of HIV-testing and attempts by both HIV-positive and negative gay men to practice serosorting.
    Psychology & Health 12/2013; 29(5). DOI:10.1080/08870446.2013.871283 · 1.95 Impact Factor
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