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HIV/AIDS stigma and psychological well-being after 40 years of HIV/AIDS: a systematic review and meta-analysis

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European Journal of Psychotraumatology
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Abstract

Background In June 2021, 40 years have passed since the first cases of HIV infection were detected. Nonetheless, people living with HIV (PLWH) still suffer from intense HIV-related distress and trauma, which is nowadays mostly linked to the still-existing stigmatization of PLWH. Objectives The aim of this systematic review and meta-analysis was to examine the association between HIV/AIDS stigma and psychological well-being among PLWH. We also explored whether this association varies as a function of sociodemographic and clinical characteristics as well as study publication year and stigma measurement. Method A structured literature search was performed on Web of Science, Scopus, PsyARTICLES, MedLine, ProQuest, and Google Scholar databases. The inclusion criteria were quantitative, peer-reviewed articles published in English between 1996 and 2020. Results After selection, 64 articles were accepted for further analysis (N = 25,294 participants). The random-effects pooled estimate revealed an overall negative and medium-strength association between stigma and well-being (r = −.31, 95% CI [−.35; −.26]). The participants’ age modified this effect with a stronger association for older PLWH. Other sociodemographic and clinical variables as well as publication year and stigma measurement did not explain the variation in association between stigma and well-being across studies. Conclusions The present meta-analysis and systematic review not only showed an expected negative relationship between stigma and well-being but also revealed a substantial heterogeneity between studies that suggests a strong role of context of a given study. This finding calls for more advanced theoretical and analytical models to identify protective and vulnerability factors to effectively address them in clinical practice and interventions.
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HIV/AIDS stigma and psychological well-being after
40 years of HIV/AIDS: a systematic review and
meta-analysis
Marcin Rzeszutek, Ewa Gruszczyńska, Małgorzata Pięta & Paula Malinowska
To cite this article: Marcin Rzeszutek, Ewa Gruszczyńska, Małgorzata Pięta & Paula Malinowska
(2021) HIV/AIDS stigma and psychological well-being after 40 years of HIV/AIDS: a systematic
review and meta-analysis, European Journal of Psychotraumatology, 12:1, 1990527, DOI:
10.1080/20008198.2021.1990527
To link to this article: https://doi.org/10.1080/20008198.2021.1990527
© 2021 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
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REVIEW ARTICLE
HIV/AIDS stigma and psychological well-being after 40 years of HIV/AIDS:
a systematic review and meta-analysis
Marcin Rzeszutek
a
, Ewa Gruszczyńska
b
, Małgorzata Pięta
a
and Paula Malinowska
b
a
Faculty of Psychology, University of Warsaw, Warsaw, Poland;
b
Faculty of Psychology, SWPS University of Social Sciences and Humanities,
Warsaw, Poland
ABSTRACT
Background: In June 2021, 40 years have passed since the rst cases of HIV infection were
detected. Nonetheless, people living with HIV (PLWH) still suer from intense HIV-related
distress and trauma, which is nowadays mostly linked to the still-existing stigmatization of
PLWH.
Objectives: The aim of this systematic review and meta-analysis was to examine the associa-
tion between HIV/AIDS stigma and psychological well-being among PLWH. We also explored
whether this association varies as a function of sociodemographic and clinical characteristics as
well as study publication year and stigma measurement.
Method: A structured literature search was performed on Web of Science, Scopus,
PsyARTICLES, MedLine, ProQuest, and Google Scholar databases. The inclusion criteria were
quantitative, peer-reviewed articles published in English between 1996 and 2020.
Results: After selection, 64 articles were accepted for further analysis (N = 25,294 participants).
The random-eects pooled estimate revealed an overall negative and medium-strength asso-
ciation between stigma and well-being (r = −.31, 95% CI [−.35; −.26]). The participants’ age
modied this eect with a stronger association for older PLWH. Other sociodemographic and
clinical variables as well as publication year and stigma measurement did not explain the
variation in association between stigma and well-being across studies.
Conclusions: The present meta-analysis and systematic review not only showed an expected
negative relationship between stigma and well-being but also revealed a substantial hetero-
geneity between studies that suggests a strong role of context of a given study. This nding
calls for more advanced theoretical and analytical models to identify protective and vulner-
ability factors to eectively address them in clinical practice and interventions.
Estigma del VIH/SIDA y bienestar psicológico después de 40 años de VIH/
SIDA: una revisión sistemática y metanálisis
Antecedentes: En junio de 2021 pasaron cuarenta años desde que fueron detectados los
primeros casos de infección por VIH. No obstante, las personas que viven con el VIH (PVCV)
todavía sufren de angustia intensa y trauma relacionados con el VIH, que en la actualidad se
vinculan principalmente con la estigmatización aún existente de las PVCV.
Objetivos: El propósito de esta revisión sistemática y metanálisis fue examinar la asociación
entre el estigma del VIH/SIDA y el bienestar psicológico entre las PVCV. También exploramos si
esta asociación varía en función de las características sociodemográcas y clínicas, así como del
año de publicación del estudio y la medición del estigma.
Método: Se realizó una búsqueda estructurada de literatura en las bases de datos Web of
Science, Scopus, PsyARTICLES, MedLine, ProQuest y Google Scholar. Los criterios de inclusión
fueron artículos cuantitativos, revisados por pares, publicados en inglés entre 1996 y 2020.
Resultados: Después de la selección, se aceptaron 64 artículos para análisis adicionales
(N = 25.294 participantes). La estimación combinada de efectos aleatorios reveló una
asociación general negativa y de intensidad media entre el estigma y el bienestar (r = −.31,
IC del 95% [−.35; −.26]). La edad de los participantes modicó este efecto con una
asociación más fuerte para las PVCV mayores. Otras variables sociodemográcas y clínicas,
así como el año de publicación y la medición del estigma, no explicaron una variación de la
asociación entre el estigma y el bienestar entre los estudios.
Conclusiones: El presente metanálisis y revisión sistemática mostró una relación negativa
esperada entre el estigma y el bienestar, pero también reveló una heterogeneidad sustancial
entre los estudios que sugiere un papel importante del contexto de cada estudio dado. Este
hallazgo requiere modelos teóricos y analíticos más avanzados para identicar factores pro-
tectores y de vulnerabilidad, para abordarlos de manera efectiva en la práctica clínica y las
intervenciones.
ARTICLE HISTORY
Received 5 May 2021
Revised 27 September 2021
Accepted 27 September 2021
KEYWORDS
HIV/AIDS stigma; well-being;
systematic review; meta-
analysis
PALABRAS CLAVE
estigma del VIH/SIDA;
bienestar; revisión
sistemática; metaanálisis
关键词
HIV/AIDS污名; 幸福感;
统综述; 元分析
HIGHLIGHTS
In this meta-analysis, the
relationship between HIV/
AIDS stigma and well-
being of people living with
HIV was investigated.
CONTACT Marcin Rzeszutek marcin.rzeszutek@psych.uw.edu.pl Faculty of Psychology, University of Warsaw, Stawki 5/7, Warsaw 00-183, Poland
Supplemental data for this article can be accessed here.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY
2021, VOL. 12, 1990527
https://doi.org/10.1080/20008198.2021.1990527
© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which
permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
HIV/AIDS 40 年后的HIV/AIDS污名和心理幸福感:一项系统综述和元分析
背景: 2021 6 , 距离发现第一例 HIV 感染病例已经过去了 40 年。尽管如此, HIV感染者
(PLWH) 仍然遭受着强烈的HIV相关痛苦和创伤, 如今这主要与仍然存在的 PLWH 污名化有
关。
目的: 本系统综述和元分析旨在考查PLWH HIV/AIDS污名与心理幸福感之间的关联。我们
还探讨了这种关联是否因社会人口统计学和临床特征以及研究发表年份和污名测量而异。
方法: Web of Science, Scopus, PsyARTICLES, MedLine, ProQuest Google Scholar 数据库上
进行了结构化文献搜索。纳入标准是 1996 年至 2020 年间以英文发表的同行评审的定量文
章。
结果: 筛选之后, 纳入了64 篇文章进行进一步分析 (N = 25,294 名参与者) 。随机效应汇总估计显
, 污名和幸福感之间总体呈中强度负相关 (r = −.31, 95% CI [−.35; −.26]) 。参与者的年龄调节了
这种效应, 年龄更大的 PLWH 有更强的关联。其他社会人口统计学和临床变量以及出版年份和
污名测量并不能解释跨研究的污名和幸福感之间关联的变异。
结论: 本元分析和系统综述表明, 污名和幸福感之间存在预期的负相关关系, 但也揭示了研究
之间的巨大异质性, 这表明给定研究背景的重要作用。这一发现需要更先进的理论和分析模
型来识别保护和易感因素, 以便在临床实践和干预中有效解决这些问题。
1. Introduction
In June 2021, 40 years have passed since the first cases of
human immunodeficiency virus (HIV) infection were
detected and described by the Centers for Disease
Control (CDC, 1981), resulting in a previously unknown
disease, Acquired Immunodeficiency Syndrome (AIDS).
Since its discovery, enormous progress in HIV treatment
has changed this disease from a terminal to a chronic
medical problem (Carrico et al., 2019). As a result, the
current average life expectancy of people living with HIV
(PLWH) does not differ significantly from the life
expectancy of the general population (Joint United
Nations Programme on HIV-AIDS; UNAIDS, 2019).
Furthermore, several recent studies have shown that
psychosocial variables outweighed the medical para-
meters as predictors and correlates of psychological
well-being (PWB) of PLWH (e.g. Cooper, Clatworthy,
Harding, Whetham, & Consortium, 2017; Rzeszutek,
Gruszczyńska, & Firląg-Burkacka, 2018). However,
PLWH still suffer from intense HIV-related distress
and consistently report a much poorer well-being
level when compared to patients suffering from
other chronic illnesses (Cooper et al., 2017).
According to several meta-analyses, this paradoxical
situation is linked to the still-existing stigmatization
of PLWH, whose explicit manifestations have chan-
ged, although its overall level remains relatively
similar to the beginning of the HIV/AIDS epidemic
(Rueda et al., 2016). In particular, HIV/AIDS stigma
is perceived by PLWH as the main source of distress
among PWB (Rendina, Brett, & Parsons, 2018) and is
still the greatest barrier to effective coping with the
HIV epidemic in health care worldwide (UNAIDS,
2019). However, despite a plethora of studies on HIV/
AIDS stigma, contemporary research on this topic
demonstrates theoretical and methodological limita-
tions and several research areas in this field remain
unexplored (Fazeli & Turan, 2019). The latter fact
precludes us still from the thorough understanding
on how HIV/AIDS stigma deteriorates PLWH’s well-
being.
From its beginnings, the definition of HIV/A
IDS stigma posed a great challenge for researchers
(Crawford, 1996; Rueda et al., 2016). The difficulties in
operationalizing the aforementioned term stemmed
from the interaction of two layers of this type of stigma,
encompassing the internal, traumatic character of HIV/
AIDS itself, as well as the external, socio-cultural issues.
On the one hand, diagnosis and life with potentially fatal
somatic disease is a very strong stressor, which from the
fourth edition of DSM was classified as an event meeting
the criterion of a traumatic stressor, leading even to post-
traumatic stress disorder (PTSD; American Psychiatric
Association [APA], 1994; Cordova, Riba, & Spiegel, 2017;
Kangas, Henry, & Bryant, 2005). The disease that has the
consequences described above is HIV/AIDS, since
roughly 28% to even 64% of HIV-infected people meet
the diagnostic criteria of PTSD (Sherr et al., 2011; Tang
et al., 2020). However, PTSD symptoms accompanying
PLWH have a complex aetiology and variable dynamics.
Although they are usually initiated by the moment of
diagnosis, they also result from a later struggle with such
a disease, constant awareness of the real-life threat, treat-
ment side effects and especially strong social stigma
(Neigh et al., 2016). In other words, trauma experienced
by PLWH applies not only to the past (see diagnosis) but
it is also an ongoing process induced by internal
(somatic) and external factors (stigma) related to the
present and/or future life of these patients. The latter
fact provoked plenty of controversial discussion on
applying the diagnosis of PTSD to PLWH (Kagee,
2008). On the other hand, HIV/AIDS stigma is rooted
also in socio-cultural factors engaged in stereotyping and
discriminating against PLWH, which mirrored existing
inequalities in class, race, gender, and sexuality (Parker &
Aggleton, 2003). Taking this complexity of the stigmati-
zation process of PLWH into account, research on HIV/
AIDS stigma lacks a theoretical model that provides not
2M. RZESZUTEK ET AL.
only a clear definition of HIV/AIDS stigma but addition-
ally proposes definitive mechanisms by which stigma
exerts its deteriorating effects on the lives of PLWH.
Instead, many studies are based on some global and
even atheoretical (built ad hoc) HIV/AIDS stigma
index, devoid of differentiating distinct mechanisms of
this stigma and their unique association with the
domains of functioning of PLWH (Rueda et al., 2016).
One exception is the HIV Stigma Framework by
Earnshaw and Chaudoir (2009), which underscores
a number of HIV stigma mechanisms that are distinct
psychological responses to the knowledge that PLWH
have about their HIV/AIDS status. More specifi-
cally, the HIV Stigma Framework distinguishes three
mechanisms of stigmatization experienced by PLWH:
internalized, anticipated, and enacted HIV/AIDS stigma.
According to Earnshaw and Chaudoir (2009), differen-
tiating between these three mechanisms of HIV/AIDS
stigma is critical to foster understanding of how HIV/
AIDS stigma affects the lives of PLWH, as each of these
stigma mechanisms may have a unique impact on psy-
chological, social, and physical components of health and
well-being in this patient group (Earnshaw, Rosenthal, &
Lang, 2016; Earnshaw, Smith, Chaudoir, Amico, &
Copenhaver, 2013). However, this model was criticized
as the data for it were obtained only in cross-sectional
studies, without control of other possible pathways of
such relationships, and the conceptualization of its out-
come components (i.e. health and well-being) was rather
poorly based on the current understanding of these con-
structs in psychology (Misir, 2015).
The methodological shortcomings of the majority
of studies devoted to HIV/AIDS stigma pertain to
either a cross-sectional design using self-report ques-
tionnaires or, less commonly, a longitudinal design
also using solely classic psychometric questionnaires
(Logie & Gadalla, 2009; Rueda et al., 2016; Smith,
Rossetto, & Peterson, 2008). These kinds of proce-
dures not only preclude causal interpretations but
also prevent grasping the processual aspect of struggling
with HIV/AIDS stigma among PLWH. Experiencing
HIV/AIDS stigma is a dynamic process, and more
advanced methods are necessary to capture the trajec-
tories of this process in longer and shorter temporal
perspectives, which may lead to different conclusions
(Rendina et al., 2018). A paucity of studies control for
distinct levels of HIV/AIDS stigma, that is, most do not
account for the mechanism of stigma accumulation via
the minority stress theory (Meyer, 2003). More specifi-
cally, it has been observed that HIV/AIDS stigma may be
intensified among sexual and gender minorities (e.g.
lesbian, gay, and bisexual PLWH), who are significantly
affected by the HIV epidemic (Cramer, Burks, Plöderl, &
Durgampudi, 2017). To be sure, not every person
infected with HIV is a sexual or gender minority, but
those who are may be prone to stigma accumulation
(Cramer et al., 2017). It has been documented in several
studies that PLWH who belong to sexual and gender
minorities have even lower well-being and worse health
than the general population of HIV/AIDS patients
(Rendina et al., 2018; Rendina, Weaver, Millar, López-
Matos, & Parsons, 2019). To further complicate the topic,
it must be taken into account that the gender and
ethnicity of PLWH may affect stigma accumulation.
Specifically, HIV-infected women have reported a lower
quality of life, more intense HIV-related stigma, and
higher rate of associated mental problems (Machtinger,
Wilson, Haberer, & Weiss, 2012). The same process of
stigma accumulation has also been observed among
PLWH representing ethnic minorities (Logie, Ahmed,
Tharao, & Loutfy, 2017). Thus, a negative synergistic
effect of being a minority in any of these three areas,
gender, sexual orientation, and ethnicity, may be
observed although it is yet to be tested.
Finally, as previously mentioned, HIV/AIDS
stigma was predominantly examined in the context
of the negative aspects of the functioning of PLWH,
searching for both stigma correlates and conse-
quences (e.g. Logie & Gadalla, 2009; Rueda et al.,
2016). However, such a broad scope of analysed vari-
ables, ranging from mental and physical health to risk
behaviours, access to health care services, and overall
social functioning, has led to ambiguous conclusions
(Rendina et al., 2019). More integrative work with
a particular focus on the well-being of PLWH and
other factors clearly defined as potential moderators
should bring more conclusive results in identifying
how well-being is related to stigma and what modifies
this relationship.
2. Objectives of the current study
Taking the aforementioned issues into consideration,
the aim of this systematic review and meta-analysis was
to synthesize, analyse, and critically review existing
studies on the association between HIV/AIDS stigma
and psychological well-being among PLWH. We fol-
lowed the broad operationalization of well-beingin par-
ticular, quality of life and health-related quality of life,
satisfaction with life, and affective components.
Moreover, in the meta-analytic portion, we aimed
to evaluate the overall strength and direction of this
relationship and searched for its possible moderators,
including year of study publication, operationalization
of stigma, and the most crucial sociodemographic (i.e.
participant age, gender, ethnicity, sexual orientation,
employment, education, and relationship status) and
clinical variables (time since HIV diagnosis, AIDS
status, CD4 count, and viral load). We also examined
the possibility of HIV/AIDS stigma accumulation,
paying specific attention to a potential synergistic
effect of moderators such as sexual and gender min-
ority status, gender, and ethnicity.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 3
3. Method
3.1. Search strategy and inclusion/exclusion
criteria
The literature search and review were conducted in
accordance with the Preferred Reporting Items for
Systematic Reviews and Meta-analyses (PRISMA) state-
ment (Moher, Liberati, Tetzlaff, & Altman, 2009;
see also Figure 1). A search was performed on
12 December 2020, in the following databases: Web of
Science, Scopus, PsyARTICLES, MedLine, ProQuest,
and Google Scholar (this was treated as an additional
source of grey literature; Bellefontaine & Lee, 2014).
The Boolean query had the following form: (HIV OR
AIDS OR (acquired AND immunodeficiency AND syn-
drome) OR (human AND immunodeficiency) OR
PLWH OR PLWHA OR HIV/AIDS OR SIDA) AND
(stigma* OR (HIV-stigma) * OR (HIV/AIDS-stigma)
AND (well-being OR wellbeing OR (well AND being)
OR (life AND satisfaction) OR life-satisfaction OR (life
AND quality) OR life-quality). We searched only for
papers written in English and published between
January 1996 (indicating the advent of combination
antiretroviral therapy [Antiretroviral Therapy; ART])
and December 2020. This specific time span was also
applied in other meta-analyses on HIV/AIDS stigma
(Logie & Gadalla, 2009; Rueda et al., 2016) and was
motivated by the fact that in 1996, HIV/AIDS evolved
from a terminal to a chronic medical condition as
a result of the introduction of ART, which result in
differences in the role of HIV/AIDS stigma on the
psychosocial functioning of PLWH compared to the
era before ART (Logie & Gadalla, 2009).
In addition to the English-language criterion, the
studies had to meet the following criteria to be
included in the systematic review and subsequently
in the meta-analysis:
(1) Type of study: We included only peer-reviewed,
quantitative, empirical articles that measured the rela-
tionship between HIV/AIDS-related stigma and well-
being outcomes among PLWH. We excluded other
systematic reviews or meta-analyses, editorials, letters,
and qualitative reports.
(2) Participants: We included studies conducted on
HIV/AIDS patients, with no restriction on gender,
age, sexual orientation, disease stage, or ethnicity.
We also included studies in which participants were
composed of PLWH and patients with other chronic
Records identified through
database searching
(
n = 8236
)
Screenin
Included Eligibility Identification
Additional records identified
through other sources
(
n = 97
)
Records after duplicates removed
(n = 6723)
Records screened
(n = 6723)
Records excluded following
title and abstract screening
(n = 6541)
Full-text articles assessed
for eligibility
(
n = 182
)
Full-text articles excluded
(n = 93)
No reliable HIV/AIDS stigma/well-
being measurement (46)
No PLWH (32)
Not quantitative (11)
Publication year before 1996 (4)
Studies assessed for
systematic review
(
n = 89
)
Studies included in
systematic review
(n = 64)
Full-text articles excluded
(n = 25)
No statistics available to be
transformed into effect size (13)
Lack of data on any covariates (8)
Duplication of the same sample (4)
Figure 1. PRISMA flow diagram of the study selection process for inclusion in the systematic review.
4M. RZESZUTEK ET AL.
illnesses. We excluded studies that focused on care-
givers or family members of PLWH.
(3) Methodology: We included only studies with
psychometrically sound measurements of HIV/AIDS
stigma and well-being outcomes and reported any one
of the following statistics: correlation coefficients and
sample sizes, regression coefficients, or other statistics
that could be transformed into a standardized effect
size. We excluded studies with no psychometric HIV/
AIDS stigma and well-being measurements (i.e. studies
with ad hoc author-created scales/items) and studies
without sufficient statistics to compute a standardized
effect size, even after contacting authors.
(4) Quality of study: We followed the Quality
Assessment Tool for Observational Cohort and Cross-
Sectional Studies (Feng et al., 2014), which consists of
14 criteria and requires the evaluator to answer whether
the study in question meets the particular criterion.
Studies were rated by three independent evaluators
(see Results and Figure 1). They paid special attention
to whether the study used a clear definition of HIV/
AIDS stigma and well-being outcomes, used validated
measures with psychometric data, controlling for socio-
demographic and clinical covariates, and provided data
to calculate effect sizes. Additionally, the articles, espe-
cially those by the same authors, were checked to ensure
that they did not use an identical sample of participants
more than once. If this was the case, only one of them
was included in the final analysis.
3.2. Statistical analysis
As the majority of studies used the global HIV/AIDS
stigma and well-being index, analysis was performed
on such global indicators. If more than one dimension
of HIV/AIDS stigma (i.e. internalized stigma, antici-
pated stigma, or enacted stigma) was considered in the
study, the result with the highest strength of associa-
tion with the outcome was selected (Rueda et al.,
2016).
Meta-analysis was performed with the use of library
‘meta’ in the R Statistics 4.03 software environment
(Schwarzer, 2007) and Pearson’s correlation coefficients
for effect size measures. The unstandardized and stan-
dardized regression coefficients obtained from single
studies, after adjustment for having the same direction
regardless of the measurement method, were trans-
formed to Pearson’s correlation coefficients following
formulas provided by Lipsey and Wilson (2001) with
the use of library ‘esc.’ A random effects model was
implemented, assuming heterogeneity of the effect size
between studies because the studies do not stem from
one population. The DerSimonian–Laird estimator of
the variance of the distribution of true effect sizes was
used. Heterogeneity in true effect sizes between studies
was evaluated by Cochran’s Q statistics (distributed as
a chi-square statistic with number of studies minus
1 degrees of freedom) and I
2
statistics (Higgins,
Thompson, Deeks, & Altman, 2003). Outliers’ diagnos-
tics were based on Baujat plot (Baujat, Mahé, Pignon, &
Hill, 2002) and Graphic Display of Heterogeneity
(GOSH) plot (Olkin, Dahabreh, & Trikalinos, 2012)
analysis. Publication bias was assessed with a contour-
enhanced funnel plot (Peters, Sutton, Jones, Abrams, &
Rushton, 2008). The potential moderators of the effect
size were analysed with meta-regression (Viechtbauer,
2010).
4. Results
4.1. Identication, screening, and eligibility
Initially, 8,333 titles and abstracts were gathered
through electronic databases, including 5,452 from
MedLine, 1,402 from Web of Science, 781 from
ProQuest, 582 from Scopus, 19 from PsyARTICLES,
and 97 from Google Scholar, which was treated as an
additional database source. After removing duplicates,
6,723 potentially eligible records remained for further
screening. Careful title and abstract screening per-
formed by three independent reviewers garnered 182
full articles for assessment, and 118 of them were
eliminated after applying the exclusion criteria.
Finally, 64 articles were accepted for further analysis.
The details of the selection process are presented in
Figure 1 in a PRISMA flow diagram.
Regarding the year of publication, the majority of
studies were published in the last five years. Included
study publication years are as follows: 2020 (9 articles,
14% of all); 2019 (7 articles, 11% of all); 2018 (7
articles, 11% of all); 2017 (7 articles, 11% of all); and
2016 (5 articles, 8% of all). In the remaining analysed
years, one to three articles from each year were eligi-
ble, with the exception of 2013, which had seven
articles, accounting for 10% of all analysed. The total
sample size was N = 25,294 PLWH, including 14,590
males, 10,682 females, and 22 participants who chose
the ‘other’ option regarding sex. 92% (59 out of 64) of
analysed studies were cross-sectional in design.
Finally, as far as the study settings are concerned (i.e.
country), more than half (51%; 33 out of 64) of the
eligible studies have been conducted in the USA.
About 15% (10 out of 64) have been carried out in
Asian regions (e.g. China, Hong Kong, Taiwan, and
Vietnam), 7% (5 out of 64) in European countries, 7%
in African countries (5 out of 64), 4% (3 out of 64) in
Canada. The rest of the studies came from other parts
of the world, such as Australia, India, Iran and
Indonesia.
The eligible studies used various measures to
assess the HV/AIDS stigma, but the most common
were the Berger HIV Stigma Scale (Berger, Ferrans, &
Lashley, 2001), the Internalized HIV Stigma instru-
ment (Sayles et al., 2008), the Barriers to Care Scale
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 5
(Heckman, Somlai, Kelly, Stevenson, & Galdabini,
1996), the HIV Stigma Framework Scale (Earnshaw
& Chaudoir, 2009), and the HIV Stigma Measure
(Sowell et al., 1997). With respect to well-being mea-
sures, quality of life was evaluated most commonly by
the WHOQOL-HIV BREF (WHOQOL Group,
1995), the Medical Outcomes Study Short-Form 36-
Item Health Survey (Stewart, Hays, & Ware, 1988),
and the HIV/AIDS Targeted Quality of Life instru-
ment (Holmes & Shea, 1998). Life satisfaction was
assessed almost exclusively by the Satisfaction with
Life Scale (Diener, Emmons, Larsen, & Griffin, 1985).
The other components of psychological well-being
were evaluated primarily by the Psychological Well-
Being Scale (Ryff, 1989) as well as the Positive and
Negative Affect Scale (Watson, Clark, & Tellegen,
1988). Table 1 summarizes the details of the 64
selected articles.
4.2. Meta-analysis: association between HIV/AIDS
stigma and well-being outcomes
4.2.1. Diagnosis of outliers and influencing cases
Possible outliers and influencing cases, that is, studies
yielding observed effects outlying or well-separated
from the rest of the data, were identified with
a Baujat plot. Results of the Baujat plot are depicted
in Figure 2. The plot shows the contribution of each
study to the overall Q-test statistic for heterogeneity
on the horizontal axis versus the influence of each
study on the overall result on the vertical axis. As can
be seen, especially in the case of Study 33 (i.e. Miller
et al., 2016), some studies appeared to contribute
heavily to overall heterogeneity and, as such, may
have a strong influence on the overall results.
However, since careful inspection of this study did
not identify any specificity, we decided to conduct
GOSH plot analysis to further detect outliers and
influential studies. In Figure 3, the pooled effect size
is presented on the x-axis and the between-study
heterogeneity on the y-axis. As seen, the obtained
model formed a unimodal distribution, with domina-
tion of high between-study heterogeneity. Since gra-
phical analysis showed no multimodality, we decided
not to remove any study from the subsequent
analyses.
4.2.2. Publication bias
The potential publication bias effect was examined
with a contour-enhanced funnel plot. The results are
depicted in Figure 4, which shows that in general,
small studies appear to be under-represented in the
areas of both high and no statistical significance. Thus,
although publication bias cannot be excluded, this
may suggest that the observed asymmetry is caused
by other factors, such as the real absence of smaller
studies due to their known insufficient power to detect
the effect in question. The mean sample size of the
studies included in the meta-analysis is 392.22
(SD = 499.89), ranging from 41 to 2987, and 14% of
studies had a sample size below 100 participants.
Additionally, sample characteristics as well as study
quality, not only statistical significance, may favour
publication of larger studies.
4.2.3. Effect sizes and heterogeneity
The effect sizes for individual studies ranged from −.90
to .04 and overlap in the confidence interval was
minimal (Figure 5). This heterogeneity was significant,
(Q(63) = 1242.65, p < .001, I
2
= 94.9% [94.1%; 95.6%]),
indicating that 95% of the total variation in estimated
effects was due to between-study variation, which was
considered to be high (Higgins et al., 2003). The ran-
dom-effects pooled estimate revealed a negative and
medium-size (Cohen, 1988) association between
stigma and subjective well-being (r = −.31, 95% CI
[−.36; −.26]). However, a 95% prediction interval
[−.77; .13] informing on the range of true effects in
similar future studies suggests that this association
may be from negative to null or even slightly positive
(IntHout, Ioannidis, Rovers, & Goeman, 2016).
4.2.4. Moderators
In the next step, possible moderators of the obtained
effect size were examined through meta-regression.
They included publication year, operationalization of
stigma, and sociodemographic and clinical character-
istics. There was no evidence of variation in the effect
size due to publication year (B = −.01, p > .05) or the
Berger’s scale versus other tools to assess stigma
(B = .03, p > .05). The observed effect size also did
not change with percentage of male participants in the
study (B = −.06, p > .05), being in a stable relationship
(B = .04, p > .05), higher education (B = −.09, p > .05),
or stable employment (B = .06, p > .05). Similarly,
statistically insignificant results were noted for the
percentage of participants with heterosexual orienta-
tion (B = .01, p > .05) and Caucasian ethnicity versus
other ethnicities (B = −.16, p > .05). For clinical vari-
ables, all the effects were insignificant, including mean
viral load (B = .21, p > .05), mean time since diagnosis
(B = −.01, p > .05), and AIDS status (B = −.08, p > .05).
Thus, only two moderators were identified: mean age
of the participants, (B = −.01, p < .05) and mean CD4
count (B = −.01, p < .05). However, values for CD4
count became insignificant when controlled for parti-
cipant age. Thus, mean age of the participants was the
only significant moderating variable, modifying the
stigma-well-being effect, which is presented in
Figure 6 using a bubble plot with a circle size
6M. RZESZUTEK ET AL.
Table 1. Summary of literature investigating association between HIV/AIDS stigma and psychological well-being among people living with HIV.
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
1. Heckman et al. 1997
USA
Cross-
sectional
Barriers to Care
Scale
Life satisfaction
(Satisfaction with
Life Scale)
N = 275;
Male (M) = 221,
Females
(F) = 53,
Other (O) = 1;
Age
mean = 36.8
n/a 72%
Caucasian,
19%
African
American,
3% Latino,
6% other
34% higher
education
36% AIDS Gender (lower life satisfaction and higher
stigma in women)
2. Heckman et al. 2002
USA
Cross-
sectional
Barriers to Care
Scale
Quality of life (HIV-
specific overall
quality of life [QL];
HIV-Related Life
Stressor Burden
Scale)
N = 83;
M = 69,
F = 14;
Age
mean = 55.2
Homo
(HM) = 44,
Hetero
(HT) = 28,
Bi (B) = 11
51%
Caucasian,
38%
African
American,
11%
other
100% higher
education;
26% stable
relationship;
11% employed
65% detectable
viral load; 55%
AIDS
Ethnicity (lower quality of life [QL] and higher
stigma in Caucasians compared to other
studied ethnicities), employment (higher
QL and lower stigma), and AIDS status
(lower QL and higher stigma)
3. Heckman et al. 2004
USA
Cross-
sectional
Barriers to Care
Scale
Psychological well-
being (emotional
aspects; Functional
Assessment of HIV
Infection Scale)
N = 329;
M = 237,
F = 92;
Age
mean = 41.9
HM = 243,
HT = 56,
B = 2
74%
Caucasian,
17%
African
American,
9%,
Latino
41% higher
education;
40% stable
relationship;
83% employed
9.6 years since
diagnosis/
treatment; 46%
AIDS
AIDS status (lower well-being and higher
stigma)
4. Kang et al. 2005
USA
Cross-
sectional
Social Impact
Scale
Psychological well-
being (physical
aspects; Adult AIDS
Clinical Trials
Group)
N = 53;
M = 45,
F = 8;
Age
mean = 42.1
HM = 23,
HT = 28,
B = 2
56% Chinese,
9%
Filipino, 19%
Southeast
Asian,
9% Japanese,
7% other
46% higher
education;
21% stable
relationship;
64% employed
Mean CD4:
260.20; 52%
detectable viral
load; 6.1 years
since diagnosis/
treatment; 38%
AIDS
Ethnicity (lowest well-being and higher
stigma in Asians compared to other studied
ethnicities)
5. Ramirez-Valles
et al.
2005
USA
Cross-
sectional
Experienced
Homosexual
Stigma Scale
Psychological well-
being (cognitive
and social aspects;
Rosenberg Self-
Esteem Scale)
N = 155;
M = 155;
Age
mean = 39.5
HM = 155 100% Latino 26% higher
education
n/a Sexual orientation (Homosexuality-based
stigma associated with lower well-being)
and education (higher education buffered
effects of HIV stigma on well-being)
6. Murphy et al. 2006
USA
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (emotional
aspects; Health-
Related Anxiety
Scale)
N = 118;
F = 118;
Age
mean = 39.6
HT = 118 66.9% Latino,
29.7%
African
American,
1.7%
Caucasian,
1.7% other
23.9% higher
education;
23% stable
relationship;
27.1% employed
Mean CD4:
330.60; 58.6%
detectable viral
load
Medical status (higher well-being and lower
stigma associated with higher mean CD4
and undetectable viral load)
(Continued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 7
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
7. Swendeman et al. 2006
USA
Longitudinal HIV Stigma
Measure
Quality of life
(physical aspects;
HIV/AIDS
Progression Scale)
N = 147;
M = 116,
F = 31;
Age
mean = 23.2
HM = 101,
HT = 46
44%
Latino, 24.5%
African
American,
24.5%
Caucasian,
7% other
56% higher
education
26.5% AIDS Gender (higher stigma and lower QL in
women) and sexual orientation
(homosexual orientation associated with
higher stigma)
8. Mak et al. 2007
Hong Kong
Longitudinal Self-Stigma Scale Psychological well-
being (emotional
aspects; Mental
Health Inventory)
N = 119;
M = 102,
F = 17;
Age
mean = 42.08
HM = 26,
HT = 87,
B = 6
100%
Chinese
1.7% higher
education;
9.8% stable
relationship;
61.9% employed
17.5% detectable
viral load;
5.2 years since
diagnosis/
treatment
No significant covariates
9. Buseh et al. 2007
USA
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
the revised Sign
and Symptom
Check-List for HIV)
N = 55;
M = 55;
Age
mean = 48.08
HM = 35,
HT = 20
100% African
American
36% higher
education;
16% stable
relationship;
11% employed
31% detectable
viral load;
10.79 years
since diagnosis/
treatment;
18.5% AIDS
Education (higher education associated with
lower stigma and higher QL) and AIDS
status (lower QL and higher stigma)
10. Holzemer et al. 2009
USA, various
African
countries,
Puerto
Rico
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
HIV/AIDS Targeted
Quality of Life
instrument)
N = 726;
M = 395,
F = 331;
Age
mean = 42.69
n/a 29.7%
African
American
27.6%,
Latino,
21,0%
Caucasian,
21,7%
other
27.6% higher
education
41% AIDS Ethnicity (higher stigma and lower QL in
African Americans compared to other
studied ethnicities)
11. Abboud et al. 2010
Lebanon
Cross-
sectional
HIV Stigma
Measure
Quality of life (HIV-
specific overall QL;
Multidimensional
Quality of Life-HIV)
N = 41;
M = 32,
F = 9;
Age
mean = 36.33
n/a 100% Asian 24.4% higher
education;
34.1% stable
relationship;
43.9% employed
7.5% detectable
viral load;
6.1 years since
diagnosis/
treatment;
12.5% AIDS
Relationship (being in a stable relationship
associated with lower stigma and higher
QL)
12. Greef et al. 2010
Lesotho,
Malawi,
South
Africa,
Swaziland,
Tanzania.
Longitudinal HIV/AIDS Stigma
Instrument
Quality of life (HIV-
specific overall QL;
HIV/AIDS Targeted
Quality of Life
instrument)
N = 446;
M = 121,
F = 325;
Age
mean = 35.4
n/a 100% African 5% higher
education;
28% stable
relationship;
30% employed
Mean CD4: 332.30;
3.1 years since
diagnosis/
treatment
Medical treatment (ART treatment
associated with lower stigma and higher
QL)
(Continued)
8M. RZESZUTEK ET AL.
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
13. Wagner et al. 2010
Canada
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (emotional
aspects: items from
the Hospital
Anxiety and
Depression Scale)
N = 159;
F = 159;
Age
mean = 37.7
HT = 159 65%
African
American,
19.5%
Caribbean,
6.5%
Caucasian,
9% other
66% higher
education;
49% stable
relationship
Mean CD4: 630.4;
34.4%
detectable viral
load; 9.2 years
since diagnosis/
treatment
Education (higher education associated with
lower stigma and higher well-being)
14. Andrino-
poulos et al.
2011
USA
Cross-
sectional
Berger HIV
Stigma Scale
Life satisfaction
(items from
Diabetes Quality of
Life)
N = 179;
F = 179;
Age
mean = 22.3
n/a 73%
African
American,
21%
Latino, 6%
other
11% higher
education;
53.6% stable
relationship
Mean CD4: 290.64;
86% detectable
viral load
Ethnicity (higher stigma and lower QL in
African Americans compared to other
studied ethnicities) and education (higher
education associated with lower stigma
and higher QL)
15. Li et al. 2011
China
Cross-
sectional
HIV/AIDS-Related
Stigma and
Discrimination
Scale
Quality of life (HIV-
specific overall QL;
Chinese HIV/AIDS
Quality of Life
Scale)
N = 202;
M = 144;
F = 58;
Age
mean = 33.2
n/a 100%
Asian
4% higher
education;
51% stable
relationship;
8% employed
Mean CD4: 310.2;
2.6 years since
diagnosis/
treatment
Medical treatment (longer treatment
duration and adherence associated with
lower stigma and higher QL)
16. Rao et al. 2012
China
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
Medical Outcomes
Study-HIV)
N = 120;
M = 98;
F = 22;
Age
mean = 36.1
n/a 100%
Asian
4% higher
education;
55% stable
relationship;
54% employed
Mean CD4: 211.3 Age (older age associated with higher stigma
and lower QL), employment (lower stigma
and higher QL), and education (higher
education associated with lower stigma
and higher QL)
17. Varni et al. 2012
USA
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (cognitive
aspects; Rosenberg
Self-Esteem Scale)
N = 203;
M = 146,
F = 57;
Age
mean = 43.18
HM = 85,
HT = 86,
B = 32
81%
Caucasian,
19% other
None reported 10.64 years since
diagnosis/
treatment
Gender (higher stigma and lower QL in
women) and age (older age associated
with higher stigma and lower QL)
18. Brener et al. 2013
Australia
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (cognitive
aspects; Rosenberg
Self-Esteem Scale)
N = 697;
M = 662,
F = 32, O = 3;
Age
mean = 43.67
HM = 611,
HT = 49,
B = 37
n/a 19.7% higher
education;
35.9% stable
relationship;
64% employed
13.84 years since
diagnosis/
treatment
Age (older age associated with higher stigma
and lower well-being) and years since
diagnosis (longer HIV-infection duration
associated with lower stigma and higher
well-being)
19. Earnshaw et al. 2013
USA
Cross-
sectional
HIV Stigma
Framework
Scale
Psychological well-
being (cognitive
and affective
aspects; Illness
Cognitions
Questionnaire)
N = 95;
M = 47,
F = 48;
Age
mean = 49.34
HM = 20,
HT = 75
51.6%
Caucasian,
48.4%
African
American
58.9% higher
education;
72% employed
Mean CD4: 340.2;
15.56 years
since diagnosis/
treatment
Gender (higher affective well-being and
lower stigma in women), ethnicity (higher
affective well-being and lower stigma in
African Americans), and education (higher
education associated with higher affective
well-being and lower stigma)
20. Emlet et al. 2013
USA
Cross-
sectional
Homosexual
Stigma Scale
Quality of life (mental
aspects; Medical
Outcomes Study
Short-Form 36-
Item Health
Survey)
N = 226;
M = 226;
Age
mean = 62,97
HM = 210,
B = 16
77%
Caucasian,
23% other
63.50% higher
education;
34.9% stable
relationship;
79% employed
43% AIDS No significant covariates
(victimization as homosexual stigma
component associated with lower QL in the
whole sample)
(Continued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 9
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
21. Hutton et al. 2013
Australia and
USA
Cross-
sectional
HIV version of the
Unsupportive
Social
Interactions
Inventory
Life satisfaction
(Personal
Wellbeing Index)
N = 274;
M = 250,
F = 24;
Age
mean = 47.05
HM = 216,
HT = 40,
B = 18
100%
Caucasian
33.2% stable
relationship;
32.1% employed
13.54 years since
diagnosis/
treatment;
13.9% AIDS
Age (older age associated with lower stigma
and higher life satisfaction)
22. Sanjuan et al. 2013
Spain
Cross-
sectional
Prejudice
Perception
Scale
Affective well-being
(Positive and
Negative Affect
Scale)
N = 133;
M = 97,
F = 36;
Age
mean = 39.11
n/a 100%
Caucasian
27.8% higher
education;
10% stable
relationship;
71% employed
10.01 years since
diagnosis/
treatment
Relationship (being in a stable relationship
associated with lower stigma and higher
well-being)
23. Slater et al. 2013
USA
Cross-
sectional
Internalized HIV
Stigma
instrument
Quality of life (HIV-
specific overall QL;
HIV/AIDS Targeted
Quality of Life
instrument)
N = 60;
M = 60;
Age
mean = 54.6
HM = 60 56.7%
Caucasian,
41.7%
African
American
1.6%
Asian
11.7% higher
education;
30% stable
relationship;
61% employed
15.2 years since
diagnosis/
treatment
Age (older age associated with higher QL, but
when stigma was included in the model,
age appeared to be insignificant with QL)
24. Storholm et al. 2013
USA
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (Ryff Scales
of Psychological
Well-Being)
N = 904;
M = 640,
F = 264;
Age
mean = 55.53
HM = 277,
HT = 627
87%
“Non-white,”
13%
Caucasian
49.67% higher
education
n/a Sexual orientation (homosexual orientation
associated with higher stigma and lower
well-being)
25. Fuster-
Ruizdeapodaca
et al.
2014
Spain
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life
(physical,
psychological, and
social aspects;
Quality of Life
Questionnaire)
N = 557;
M = 390,
F = 157, O = 10;
Age
mean = 43.43
HM = 182,
HT = 311,
B = 64
100%
Caucasian
15.1% higher
education;
31.4% stable
relationship;
38% employed
Mean CD4: 557.8;
37.3%
detectable viral
load; 13.5 years
since diagnosis/
treatment
No significant covariates
26. Levi-Minzi et al. 2014
USA
Cross-
sectional
Internalized HIV
Stigma
instrument
Psychological well-
being (social
aspects; Attitudes
Towards HIV
Health Care
Providers Scale)
N = 503;
M = 299,
F = 204;
Age
mean = 46.07
n/a 67.6% African
American,
32.4%
other
43.5 higher
education;
18.9% employed
12.5 years since
diagnosis/
treatment
Ethnicity (higher stigma and lower well-
being in African Americans compared to
other studied ethnicities) and medical
treatment (years in treatment positively
associated with lower stigma and higher
well-being)
27. Ammirati et al. 2015
USA
Cross-
sectional
HIV Stigma Scale Psychological well-
being (physical,
psychological and
social aspects;
General Well-Being
Schedule)
N = 116;
M = 67,
F = 49;
Age
mean = 31.20
n/a 84%
African
American,
16%
Caucasian
47% higher
education;
28% employed
n/a No significant covariates
28. Li et al. 2015
China
Cross-
sectional
HIV/AIDS-Related
Stigma and
Discrimination
Scale
Quality of life
(mental aspects;
Medical Outcomes
Study Short-Form
36-Item Health
Survey)
N = 114;
M = 79,
F = 35;
Age
mean = 39.30
n/a 100% Asian 9% higher
education;
51% stable
relationship;
51% employed
Mean CD4: 142.1;
100%
detectable viral
load; 1.6 years
since diagnosis/
treatment
No significant covariates
(Continued)
10 M. RZESZUTEK ET AL.
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
29. Wu et al. 2015
China
Cross-
sectional
HIV/AIDS-Related
Stigma and
Discrimination
Scale
Quality of life (mental
aspects; Medical
Outcomes Study
Short-Form 36-
Item Health
Survey)
N = 190;
M = 137,
F = 53
Age
mean = 38.30
n/a 100% Asian 14.7% higher
education;
55.8% stable
relationship;
26.8% employed
Mean CD4: 211.2;
2.9 years since
diagnosis/
treatment
Medical variables (Mean CD4 positively
associated with lower stigma and higher
QL) and medical treatment (years in
treatment positively associated with lower
stigma and higher QL)
30. Earnshaw et al. 2016
USA
Cross-
sectional
HIV Stigma
Framework
Scale
Psychological well-
being (social
aspects; Social
Well-Being Scale)
N = 93;
M = 55,
F = 35, O = 3;
Age
mean = 50.07
HM = 17,
HT = 76
61.3%
Caucasian,
38.7%
Latino
64.5% higher
education
18.1 years since
diagnosis/
treatment
Sexual orientation (homosexual orientation
associated with higher stigma and lower
well-being) and education (higher
education associated with lower stigma
and higher well-being)
31. Fekete et al. 2016
USA
Cross-
sectional
Berger HIV
Stigma Scale
Life satisfaction (HIV/
AIDS Targeted
Quality of Life
instrument)
N = 140;
M = 102,
F = 38;
Age
mean = 42.77
n/a 50.8%
Caucasian,
45%
African
American,
4.2%
other
23.6% higher
education;
27.9% stable
relationship;
46.7% employed
11.66 years since
diagnosis/
treatment
Gender (higher stigma and lower life
satisfaction in women)
32. Garrido-
Hernansaiz et al.
2016
India
Cross-
sectional
HIV-Related
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 961;
M = 396,
F = 565;
Age
mean = 33.12
HM = 68,
HT = 893
100% Indian 13.9% higher
education;
44.7% stable
relationship;
77.3% employed
n/a Relationship (higher QL and lower stigma in
single persons) and higher education and
employment (both associated with higher
QL and lower stigma)
33. Miller et al. 2016
USA
Longitudinal Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 216;
M = 159,
F = 57;
Age
mean = 47.86
HM = 103,
HT = 113
75.9%
Caucasian,
24.1%
other
n/a 15.46 years since
diagnosis/
treatment
No significant covariates
34. Song et al. 2016
China
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 125;
M = 125;
Age
mean = 30.07
HM = 125 100% Asian 42.4% higher
education;
13.6% stable
relationship;
45.6% employed
Mean CD4: 340.5 Medical variables (Mean CD4 positively
associated with lower stigma and higher
QL)
35. Alsayed et al. 2017
USA
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life
(physical aspects;
Medical Outcomes
Study Short-Form
36-Item Health
Survey)
N = 178;
F = 178;
Age
mean = 41.70
n/a 62.4% African
American;
37.6%
Caucasian
66.3% higher
education;
24.2% stable
relationship;
27.5% employed
65% detectable
viral load
Age (older age associated with lower stigma
and higher QL in women), ethnicity
(higher stigma and lower QL in African
Americans compared to other studied
ethnicities), relationship (being in a stable
relationship associated with lower stigma
and higher QL), and education (higher
education associated with higher QL and
lower stigma)
(Continued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 11
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
36. Cramer et al. 2017
USA
Cross-
sectional
Victim Experience
Questionnaire
Affective well-being
(Positive and
Negative Affect
Scale)
N = 154;
M = 134,
F = 15, O = 5;
Age
mean = 42.41
HM = 154 42.9%
Caucasian,
40.9
African
American,
16.2%
other
n/a n/a Gender (higher stigma/ minority stress [as
LGB status] and lower well-being in
women)
37. Jang & Bakken 2017
USA
Cross-
sectional
Internalized HIV
Stigma
instrument
Quality of life
(Medical Outcomes
Study Short-Form
36-Item Health
Survey)
N = 292;
M = 190,
F = 102;
Age
mean = 46.70
n/a 75%
Caucasian,
25%
Latino
24% higher
education;
18% employed
Mean CD4: 310.2;
37% AIDS
Gender (higher stigma and lower QL in men)
and education (higher education
associated with higher stigma and lower
QL)
38. Logie et al. 2017
Canada
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 173;
F = 173;
Age
mean = 40.70
n/a 69.5%
African,
30.5%
Caribbean
16.2% higher
education;
32.7% stable
relationship;
33.2% employed
n/a Ethnicity (higher stigma/racial discrimination
and lower QL in African Americans
compared to other studied ethnicities)
39. Porter et al. 2017
USA
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (Ryff Scales
of Psychological
Well-Being)
N = 914;
M = 648,
F = 266;
Age
mean = 55.50
HM = 302,
HT = 612
52%
African,
34% Latino,
14%
Caucasian
49% higher
education;
77.1% employed
Mean CD4: 468.2;
33% detectable
viral load;
12.6 years since
diagnosis/
treatment; 51%
AIDS
No significant covariates
40. Veld et al. 2017
South Africa
Cross-
sectional
Internalized
AIDS-Related
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 2230;
M = 747,
F = 1483;
Age
mean = 37.10
n/a n/a 8.8% higher
education;
30.9% stable
relationship;
51.4% employed
Mean CD4: 166.5;
17.1%
detectable viral
load; 22 years
since diagnosis/
treatment
No significant covariates
41. Vincent et al. 2017
USA
Cross-
sectional
HIV-Related
Shame Scale
Quality of life
(emotional
aspects; Functional
Assessment of
Human
Immunodeficiency
Virus
Infection)
N = 299;
M = 199,
F = 100;
Age
mean = 55.23
HM = 137,
HT = 162
49.2%
African,
29.1
Caucasian,
8.7%
Latino,
13% other
21% higher
education;
45% employed
12.41 years since
diagnosis/
treatment
Gender (stigma-related shame associated
with lower well-being only in women, but
higher stigma-related loneliness in men)
42. Ekstrand et al. 2018
India
Cross-
sectional
Internalized
Stigma Scale
Quality of life (social
aspects; Quality of
life Enjoyment and
Satisfaction
Questionnaire)
N = 600;
F = 600;
Age
mean = 34.30
n/a 100% Indian 14.5% higher
education;
39.6% stable
relationship;
3% employed
4.2 years since
diagnosis/
treatment
Relationship (being in a stable relationship
associated with higher stigma and lower
QL), age (older age associated with higher
stigma and lower QL), and medical
treatment (longer treatment duration and
adherence associated with lower stigma
and higher QL)
(Continued)
12 M. RZESZUTEK ET AL.
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
43. Lacombe-Duncan
& Chuang
2018
Taiwan
Cross-
sectional
Internalized HIV
Stigma
instrument
Life satisfaction
(Satisfaction with
Life Scale)
N = 355;
M = 272,
F = 83;
Age
mean = 36.88
HM = 178,
HT = 177
100% Asian 34.8% higher
education;
20.5% employed
Mean CD4: 460.8;
5.72 years since
diagnosis/
treatment
Higher education and employment (both
associated with lower stigma and higher
life satisfaction, though only in men)
44. Logie et al. 2018
Canada
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life
(Medical Outcomes
Study Short-Form
36-Item Health
Survey)
N = 1425;
F = 1425
Age
mean = 43.10
n/a 81.4%
Caucasian,
18.6%
other
84% higher
education;
32.18% stable
relationship;
34.5% employed
n/a Gender (higher stigma and lower QL in
women)
45. Nobre et al. 2018
Finland
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life
(physical and
psychological
aspects; 15-D
Measure of Health-
Related Quality of
Life)
N = 440;
M = 336,
F = 104;
Age
mean = 47.50
HM = 242,
HT = 180,
B = 18
86.1%
Caucasian,
13.9%
other
31.7% higher
education;
52.7% stable
relationship;
66.9% employed
CD4 mean: 510.2;
14.4%
detectable viral
load; 10.8 years
since diagnosis/
treatment;
30.2% AIDS
Gender (higher stigma and lower QL in
women), employment (lower stigma and
higher QL), relationship (being in a stable
relationship associated with higher QL and
lower stigma), and education (higher
education associated with higher stigma
and lower QL)
46. Rasoolinajad et al. 2018
Tehran
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 450;
M = 266,
F = 184;
Age
mean = 37.29
n/a 100% Iranian 14.5% higher
education;
30.7% stable
relationship;
13.9% employed
Mean CD4: 487.81 Education (higher education associated with
higher QL and lower stigma) and
relationship (being in a stable relationship
associated with lower stigma and higher
QL)
47. Rendina et al. 2018
USA
Longitudinal Berger HIV
Stigma Scale
Affective well-being
(Profile of Mood
States Scale)
N = 50;
M = 50;
Age
mean = 38.70
HM = 44,
B = 6
34%
African,
30%
Latino,
20%
Caucasian,
16%
other
10% higher
education;
24% stable
relationship;
42% employed
10.8 years since
diagnosis/
treatment
No significant covariates
48. Tran et al. 2018
Vietnam
Cross-
sectional
Substance Abuse
Stigma Scale
Quality of life
(physical and
psychological
aspects; EuroQol)
N = 1133;
M = 850,
F = 283;
Age
mean = 34.20
n/a 100% Asian 5.9% higher
education;
61.5% stable
relationship;
73.9% employed
Mean CD4: 294.7;
3.5 years since
diagnosis/
treatment; 9.6%
AIDS
Medical treatment (ART treatment duration
associated with lower stigma and higher
QL)
49. den Daas et al. 2019
Denmark
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (emotional
aspects: items from
the Hospital
Anxiety and
Depression Scale)
N = 170;
M = 159,
F = 11;
Age
mean = 33.20
n/a n/a n/a n/a No significant covariates
(Continued)
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 13
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
50. Kalan et al. 2019
Iran
Cross-
sectional
Iranian version of
the HIV/AIDS
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 200;
M = 153,
F = 47;
Age
mean = 34.20
n/a 100% Iranian 60.5% higher
education;
33.5% stable
relationship;
50.2% employed
Mean CD4: 320.3;
14.2 years since
diagnosis/
treatment; 32%
AIDS
Age (older age associated with higher stigma
and lower QL), education (higher
education associated with higher stigma
and lower QL), and employment
(associated with lower stigma and higher
QL)
51. Laschober et al. 2019
USA
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
H-QoL measure
AIDS Clinical Trials
Group)
N = 346;
M = 191,
F = 155;
Age
mean = 45.50
HM = 167,
HT = 179
63.3%
Caucasian,
36.7%
other
20.2% higher
education;
68% employed
12.8 years since
diagnosis/
treatment
No significant covariates
52. Porter et al. 2019
USA
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (Ryff Scales
of Psychological
Well-Being)
N = 640;
M = 640;
Age
mean = 55.69
HM = 247,
HT = 364,
B = 29
49.5%
African,
33.8%
Latino,
16.7%
Caucasian
25.3% higher
education;
77.1% employed
Mean CD4: 443.39;
13.13 years
since diagnosis/
treatment; 54%
AIDS
Age (older age associated with higher stigma
and lower well-being) and sexual
orientation (Homosexual orientation
associated with higher stigma and lower
well-being)
53. Rendina et al. 2019
USA
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life
(physical aspects
and treatment
adherence; TLFB
interview)
N = 120;
M = 81,
F = 39;
Age
mean = 54.60
HM = 52,
HT = 68
75.8%
African,
15%
Caucasian,
9.2%
Latino
52.5% higher
education;
20% employed
Mean CD4: 330.2;
42% detectable
viral load;
17.1 years since
diagnosis/
treatment; 44%
AIDS
Medical variables (higher mean CD4
associated with lower stigma and higher
QL) and treatment (treatment duration
associated with lower stigma and higher
QL)
54. Shrestha et al. 2019
Nepal
Cross-
sectional
AIDS-Related
Stigma Scale
Quality of life (HIV-
specific overall
QQL; WHOQOL-HIV
BREF)
N = 599;
M = 305,
F = 294;
Age
mean = 38.20
n/a 100% Asian 14.7% higher
education;
64.9% stable
relationship;
67.1% employed
Mean CD4: 430.3;
5.3 years since
diagnosis/
treatment
No significant covariates
55. Relf et al. 2019
USA
Cross-
sectional
HIV Stigma Scale Quality of life (Brief
Health Status
Assessment
Instrument for Use
in HIV disease)
N = 123;
M = 123;
Age
mean = 43.29
n/a 75.6% African
American,
15.5%
Caucasian,
8.9%
Latino
30% higher
education,
43.4% stable
relationship,
41.5% employed
n/a Age, gender (higher stigma and lower QL in
older women)
56. Chan et al. 2020
Hong Kong
Cross-
sectional
Self-Stigma Scale Life satisfaction
(Satisfaction with
Life Scale)
N = 289;
M = 277,
F = 12;
Age
mean = 41.80
HM = 220,
HT = 60,
B = 9
100% Asian 46.5% higher
education;
26.4% stable
relationship;
63.3% employed
5.4 years since
diagnosis/
treatment
Education (higher education associated with
lower stigma and higher life satisfaction)
57. Chapman-
Lambert et al.
2020
USA
Cross-
sectional
HIV Stigma
Framework
Scale
Quality of life
(physical and
psychological
aspects; EuroQol)
N = 335;
M = 267,
F = 68;
Age
mean = 37.60
HM = 221,
HT = 114
51.9%
African,
27.8%
Caucasian,
20.3%
other
34.2% employed Mean CD4: 380.6;
71.7%
detectable viral
load; <1 year
since diagnosis/
treatment
Gender (lower quality of life and higher
stigma in women) and ethnicity (higher
stigma and lower quality of life in non-
Caucasian participants compared to other
studied ethnicities)
(Continued)
14 M. RZESZUTEK ET AL.
Table 1. (Continued).
Author
Year and
study setting
(country)
Study
design Stigma measure Well-being measure
Sample: gender
and age
Sexual
orientation Ethnicity
Sociodemographic
characteristics
HIV-related clinical
variables Significant sociomedical covariates
58. Doric 2020
Serbia
Cross-
sectional
HIV Stigma Scale Subjective well-being
(Satisfaction with
Life Scale and
Positive and
Negative Affect
Scale)
N = 90;
M = 79,
F = 11;
Age
mean = 41.64
HM = 42,
HT = 41,
B = 7
100%
Caucasian
37.3% higher
education;
33.9% stable
relationship;
44.1% employed
7.88 years since
diagnosis/
treatment
No significant covariates
59. Nguyen et al. 2020
USA
Cross-
sectional
Lesbian and Gay
Identity Scale
Affective well-being
(NIHTB-EB Battery)
N = 371;
M = 332,
F = 39;
Age
mean = 52.10
HM = 294,
HT = 50,
B = 27
62.1%
Caucasian,
23.2%
Latino,
14.7%
African
23% higher
education
Mean CD4: 644.2;
17.3%
detectable viral
load
Sexual orientation (sexual minority status
associated with higher well-being and
lower stigma)
60. Parcesepe et al. 2020
Tanzania
Cross-
sectional
HIV/AIDS Stigma
Instrument
Quality of life (overall
QL; HIV/AIDS
Targeted Quality of
Life instrument)
N = 912;
M = 336,
F = 576;
Age
mean = 31.10
n/a 100% African 58.1% stable
relationship;
61.1% employed
Mean CD4: 210.2 Gender (lower QL and higher stigma in men)
and relationship (being in a stable
relationship associated with lower stigma
and higher quality of life)
61. Yang et al. 2020
China
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (overall
QL; Medical
Outcomes Study
Short-Form 36-
Item Health
Survey)
N = 193;
M = 193;
Age
mean = 30.10
n/a 100% Asian 67.70% higher
education;
14.5% stable
relationship;
74.6% employed
Mean CD4: 520.3;
27.5%
detectable viral
load; 3.1 years
since diagnosis/
treatment
Age (older age associated with higher stigma
and lower QL) and employment (lower
stigma and higher QL)
62. Zhou et al. 2020
China
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (overall
QL; Medical
Outcomes Study
Short-Form 36-
Item Health
Survey)
N = 2987;
M = 1881,
F = 1106;
Age
mean = 42.46
n/a 100% Asian 42% higher
education;
69% stable
relationship;
73.1% employed
Mean CD4: 390.2;
27.75%
detectable viral
load; 3.23 years
since diagnosis/
treatment
Age (older age associated with higher stigma
and lower QL), education (higher
education associated with higher QL and
lower stigma) and relationship (being in
a stable relationship associated with lower
stigma and higher QL)
63. Zhu et al. 2020
China
Cross-
sectional
Berger HIV
Stigma Scale
Quality of life (HIV-
specific overall QL;
WHOQOL-HIV
BREF)
N = 300;
M = 277,
F = 23;
Age
mean = 27.50
HM = 245,
HT = 55
100% Asian 60.7% higher
education;
12.7% stable
relationship;
83.7% employed
n/a Education (higher education associated with
higher QL and lower stigma) and
employment (higher QL and lower stigma)
64. Zulkarnain et al. 2020
Indonesia
Cross-
sectional
Berger HIV
Stigma Scale
Psychological well-
being (Ryff Scales
of Psychological
Well-Being)
N = 112;
F = 112;
Age
mean = 39.94
n/a n/a 83.1% higher
education;
57% stable
relationship
n/a No significant covariates
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 15
proportional to the weight of the individual studies. As
seen, the negative relationship between stigma and
subjective well-being was stronger for older partici-
pants. Nonetheless, mean participant age in the
individual studies explained 9.4% of the variation,
with still significant heterogeneity of the effect size
between stigma and well-being across the studies (Q
(62) = 1103.08, p < .001).
Figure 2. Heterogeneity diagnostics on Baujat plot. The numbers of the studies correspond to the numbers assigned in Table 1.
Figure 3. Graphic Display of Heterogeneity (GOSH) plot analysis. Note. In order to explore patterns of heterogeneity, the same
meta-analysis model was fitted to all possible subsets of included studies. I
2
: I-squared statistic of heterogeneity.
Figure 4. Heterogeneity diagnostics using a contour-enhanced funnel plot. The effects in the white zone are greater than p = .10;
the effects in the adjacent light blue zone are between p = .10 and p = .05; the effects in the darker blue zone are between p = .05
and p = .01; the effects outside this zone are smaller than p = .01.
16 M. RZESZUTEK ET AL.
Figure 5. Forest plot of effect sizes for individual studies, overall estimated effect, and 95% prediction interval. The numbers of the
studies correspond to the numbers assigned in Table 1. τ
2
: between-study variance I
2
: I-squared statistic of heterogeneity.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 17
Additionally, we verified if stigma accumulation,
defined as an interaction of being female, other than
heterosexual and other than Caucasian, affected the
stigma well-being effect, but this interaction as well as
all two-way interactions were insignificant.
5. Summary of main ndings and discussion
The aim of this study was to examine and critically
review the relationship between HIV/AIDS stigma
and PWB among PLWH. After the selection process,
64 articles were determined as having met the criteria
and the publication range (between 1997 and 2020).
They were subsequently analysed for content and qual-
ity, and the reported effect sizes were investigated by
meta-analysis. Despite high variability in the operatio-
nalization of both HIV/AIDS stigma and well-being, we
noticed a pattern indicating a negative relationship of
medium strength between these two constructs, with
the random-effects pooled estimate equalling −.31
(Table 1 and Figure 5). However, high between-study
heterogeneity was noted, with possible null future
effects. This raised the question of publication bias,
but the relevant analysis showed no evidence of this.
In addition, the publication year did not explain the
between-study effect heterogeneity, which may suggest
that despite more than two decades of implementation
of ART, the strength of the relationship between stigma
and the well-being of PLWH remains quite stable.
This corresponds to the observations made by
Rendina et al. (2018, 2019) that although the manifes-
tations of HIV/AIDS stigma have changed at the indi-
vidual and societal levels, its overall effect on the well-
being of people with HIV/AIDS is the same as at the
beginning of the epidemic. Historically, this result has
indicated both a widespread overestimation of past
effects and an underestimation of current effects,
which may have important implications for clinical
practice. On the other hand, it can also be a sign that
despite 40 years of great medical progress in treating
HIV/AIDS, PLWH still experience their HIV+ status
as a highly traumatizing factor (Neigh et al., 2006;
Tang et al., 2020).
As for sociodemographic covariates, eleven out of
twelve eligible studies pointed to elevated stigma and
much worse well-being among older PLWH. In meta-
analysis, age was identified as the only significant
moderator of effect size, with older adults having
a stronger negative relationship between stigma and
well-being. Currently, HIV has been increasingly diag-
nosed among older adults (UNAIDS, 2019). The
poorer quality of life among them has been found to
be a derivative of not only comorbid health conditions
that are increased by age (Heckman et al., 2002) but
also experienced stigma, which indicates a double jeo-
pardy (i.e. HIV/AIDS stigma and ageism; Emlet, 2006;
Emlet, Fredriksen-Goldsen, & Kim, 2013). As such,
this constitutes a special case of stigma accumulation
and the only case obtained in our study.
For other possible areas of HIV/AIDS stigma accu-
mulation, namely, gender (being female), sexual and
gender minority (other than heterosexual), and ethni-
city (other than Caucasian), not only was an interac-
tion effect insignificant but also no main effects were
noted. This indicates that the strength and direction of
the relationship between stigma and well-being were
not modified by a combination of the aforementioned
characteristics. However, the systematic review high-
lighted a more complex picture, as ten out of fifteen
eligible studies in this context indicated a higher HIV/
AIDS stigma and significantly poorer well-being
among female PLWH compared to male PLWH; yet
four studies found the opposite trend (Earnshaw et al.,
2016; Jang & Bakken, 2017; Parcesepe et al., 2020) and
one study showed that male PLWH suffered more
from some components of stigma than females (lone-
liness), although it did not account for gender differ-
ences in well-being (Vincent et al., 2017). In addition,
Figure 6. Moderating effect of mean participants’ age on the relationship between HIV/AIDS stigma and well-being of PLWH. The
circle sizes are proportional to the weights of individual studies in the meta-analysis. The numbers of the studies correspond to the
numbers assigned in Table 1.
18 M. RZESZUTEK ET AL.
in six out of seven eligible studies, PLWH representing
sexual and gender minorities (i.e. lesbian, gay, and
bisexual) experienced higher stigma and declared sub-
stantially lower quality of life compared to heterosex-
ual PLWH. Only Nguyen et al. (2020) found higher
well-being among PLWH representing sexual and
gender minorities compared to heterosexual PLWH,
although there was no significant difference in the
stigma level between these two groups. Furthermore,
in six out of nine eligible studies, African and/or
African American PLWH reported higher stigmatiza-
tion and lower well-being compared to PLWH of
Caucasian ethnicity, although Heckman et al. (2002)
and Earnshaw et al. (2013) observed the reverse and
Kang, Rapkin, Remien, Mellins, and Oh (2005) found
the lowest well-being and the highest stigma among
Asian PLWH. However, in all of these studies, the
moderating effect of sociodemographic variables was
tested directly, which showed a low theoretical
advancement of the studies on stigma thus far.
Similarly, employment, education, and marital sta-
tus also had some associations with both stigma and
well-being in single studies, but they were not verified
as moderators. During meta-analysis, they did not
modify the effect size, thus a protecting role of these
factors against the negative consequences of stigma on
well-being is not as universal as is often assumed
(Cooper et al., 2017; Smith et al., 2008). For instance,
Jang & Bakken, (2017), Nobre, Pereira, Roine, Sutinen,
and Sintonen (2018), and Kalan et al. (2019) observed
that higher education sometimes increases perceived
stigma and, in turn, deteriorates the well-being of
PLWH. In addition, two studies in our review con-
ducted on women with HIV in India showed that
married women experienced higher HIV/AIDS stigma
and worse well-being than those who were single
(Ekstrand et al., 2018; Garrido-Hernansaiz, Heylen,
Bharat, Ramakrishna, & Ekstrand, 2016).
For clinical covariates, such as CD4, viral load, time
since diagnosis and treatment, and AIDS status, we are
very cautious in reaching certain conclusions, as the
majority of reviewed studies did not include these vari-
ables or if they did, CD4 count and viral load status
were based on self-assessment only. Nonetheless, the
overall trend indicated by meta-analysis was that the
negative relationship between stigma and well-being
was stronger among PLWH with a higher CD4 count.
This suggests that the psychological context of being
infected with HIV, expressed by the association
between stigma and well-being, is more pronounced
for people in better health condition. This is under-
standable, as, in the presence of poor health, stigma
may be experienced differently and have less impact
on general well-being. However, this effect became zero
after including the participants’ mean age in the analy-
sis, implying a possible interdependence between age
and self-reported CD4.
5.1. Limitations and future research directions
Our systematic review and meta-analysis revealed
a strong heterogeneity among the studies, thus despite
clear selection criteria, thorough assessment of the
methodological and statistical quality of eligible articles
by independent reviewers, and established methods to
aggregate the study results, we must specify several
limitations of the obtained findings. First, we included
only published studies in the English language. Both
unpublished studies and studies published in different
languages may bring different results, particularly as
stigma, its internalization, and its social expression can
be strongly rooted in cultural context (Liamputtong,
2013). Second, even if we did not observe the effect of
the tool in measuring stigma, it was limited to the
comparison of the most popular Berger’s scale with
other questionnaires, sometimes developed ad hoc for
the purpose of a given study, where different aspects of
stigma without a relevant psychometric evaluation were
aggregated into a global stigma index. This illuminates
the fundamental problem of the lack of a conclusive
theoretically and empirically validated model of HIV/
AIDS stigma in the literature. Specifically, as was
already mentioned, research on HIV/AIDS stigma
lacks a theoretical model that provides not only a clear
definition of HIV/AIDS stigma but additionally pro-
poses definitive mechanisms by which stigma exerts its
deteriorating effects on the lives of PLWH. Instead,
many studies are based on some global and even
atheoretical (built ad hoc) HIV/AIDS stigma index,
devoid of differentiating distinct mechanisms of this
stigma and their unique association with the domains
of functioning of PLWH. Even wider heterogeneity of
well-being operationalization forced us to abandon
a similar analysis for well-being, instead of using this
term as an umbrella concept. Thus, it cannot be
excluded that for separate dimensions of well-being,
the obtained effect may differ substantially. Third, 92%
of reviewed studies were cross-sectional and adopted
only elementary statistical analysis with control for rela-
tively scarce covariates. As such, more longitudinal
studies are critical for understanding HIV/AIDS stigma
mechanisms, with more advanced models that include
its potential mediators and moderators. Thus, future
research on HIV/AIDS stigma and well-being should
be of better quality and go beyond the basic description
of the relationship into more explanatory models.
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 19
Finally, the vast majority of reviewed studies came from
the USA region, which reflects the dominance of the
USA studies in HIV/AIDS stigma research. This latter
fact calls for the need for more research on stigma in
other geographical regions, representing culturally ver-
satile samples of PLWH in the future.
6. Conclusions
The present meta-analysis and systematic review not
only indicate an expected negative relationship between
stigma and well-being but also reveal a substantial het-
erogeneity between studies that suggests a strong role of
context of a given study. This context may include not
only functional characteristics of the participants (e.g.
being a minority) but also differences in structural stigma
at both local and national levels (Hatzenbuehler, 2016).
Thus, future study designs require more advanced theo-
retical and analytical models to identify protective and
vulnerability factors to improve the ability to address
them in clinical practice and interventions for PLWH.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This study was financed bythe National Science Center in
Poland (research project no. 2019/35/B/HS6/00141).
ORCID
Marcin Rzeszutek http://orcid.org/0000-0002-4230-3806
Ewa Gruszczyńska http://orcid.org/0000-0003-1293-
9798
Information about data sharing
Data are available in Supplementary Information.
Research involving human participants
The study protocol was accepted by the institutional ethics
committee. Written informed consent was obtained from all
participants before participation in the study.
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24 M. RZESZUTEK ET AL.
... International literature frequently addresses the experience of stigma among men and women, but highlights that rejection is greater among women. This includes social inequalities, lower access to important and well-paid positions, and several forms of violence, such as physical, sexual, gender-based, and verbal, especially from intimate partners (25,26,(36)(37)(38)(39). ...
... This silencing of female voices occurs in discourses about HIV/AIDS, in line with the thoughts of Western societies. Even with distinct vulnerabilities, being a woman combined with economic, political, social, and cultural factors influences social thoughts and health strategies (35)(36)(37)(38)(39)(40). ...
... In women, gender inequalities aggravate this situation, negatively impacting the household's income. (35)(36)(37)(38)(39)(40)(41). ...
Article
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Introduction: Understanding the social representations of HIV/AIDS among women is important for the nursing team, as it allows them to provide quality care, respect patients’ needs, and facilitate the adoption of best healthcare practices. Objective: To understand the main scientific evidence available on the social representations of living with HIV/AIDS among adult women. Materials and Methods: This is a systematic review with meta-synthesis. Qualitative and mixed-methods studies were selected that evaluated, based on the social representations theory, the statements of adult women living with HIV/AIDS in journals published in the Scopus, Embase, VHL, and SciELO databases between 2013 and 2023. Results: 2295 articles were found. After duplicate removal, 65 articles were reviewed, with 42 being excluded as they failed to meet the specific criteria, which resulted in 16 articles for the final analysis. The findings were grouped into two categories subdivided into the following themes: Sexuality, gender, stigmas, vulnerabilities, preventive methods, and adherence to antiretroviral therapies. Concluding remarks: Social representations of HIV/AIDS improve nursing care considerably, reducing stigmas, improving communication, and providing psychological support, which also results in more welcoming and humanized care. In addition, they contribute to new health education strategies, individualized care planning, empowerment in social spaces, and effective promotion of treatment adherence.
... Moreover, to fully understand the mechanisms and effects of HIV-related stigma, it is imperative to acknowledge how multiple identities intersect (e.g. race, class, gender, sexual orientation) and how they impact stigma experiences [5,17,18]. Research shows that people living with HIV who are multiply stigmatized experience worse HIV treatment outcomes [19]. ...
... From a stigma-reduction intervention perspective, it is important to assess the prevalence of different manifestations of HIV-related stigma [36] and associations between individual characteristics and HIV-related stigma. Studies have shown that gender, age, sexual orientation, socioeconomic status, education, living in rural areas, being single, racism, maladaptive coping, depression, anxiety, lack of locus of control, lack of social support, and time since HIV diagnosis are significantly associated with high HIV-related stigma [17,24,25,27,34,[37][38][39][40][41]. ...
... Women are more often stigmatized than men for having HIV [17,42,58]. It demonstrates that gendered stigmatization exists in our society, which was also reflected in The variable Education level was non-significant the present study. ...
Article
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Background With access to antiretroviral therapy (ART) HIV infection is a chronic manageable condition and non-sexually transmissible. Yet, many people living with HIV still testify about experiencing HIV-related stigma and discrimination. It is well-documented that HIV-related stigma and discrimination continue to be critical barriers to prevention, treatment, care and quality of life. From an individual stigma-reduction intervention perspective, it is essential to identify individual and interpersonal factors associated with HIV-related stigma manifestations. To address this issue and to expand the literature, the aim of this study was to assess the prevalence of HIV-related stigma manifestations and their associated factors among a diverse sample of people living with HIV in Sweden. Method Data from 1 096 participants were derived from a nationally representative, anonymous cross-sectional survey ”Living with HIV in Sweden”. HIV-related stigma manifestations were assessed using the validated Swedish 12-item HIV Stigma Scale encompassing four HIV-related stigma manifestations: personalised stigma, concerns with public attitudes towards people living with HIV, concerns with sharing HIV status, and internalized stigma. Variables potentially associated with the HIV-related stigma manifestations were divided into four categories: demographic characteristics, clinical HIV factors, distress and ART adherence, and available emotional HIV-related support. Four multivariable hierarchical linear regression analyses were employed to explore the associations between multiple contributors and HIV-related stigma manifestations. Results The most dominating stigma feature was anticipation of HIV-related stigma. It was manifested in high scores on concerns with sharing HIV status reported by 78% of the participants and high scores on concerns about public attitudes towards people living with HIV reported by 54% of the participants. High scores on personalised stigma and internalized stigma were reported by around one third of the participants respectively. Between 23 and 31% of the variance of the four reported HIV-related stigma manifestations were explained mainly by the same pattern of associated factors including female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support. Conclusion The most dominating stigma feature was anticipation of stigma. Female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support constituted potential vulnerability factors of the four HIV-related stigma manifestations. Our findings highlight the vital necessity to support people living with HIV to increase their resilience to stigma in its different forms. Exploring associated factors of HIV-related stigma manifestations may give an indication of what circumstances may increase the risk of stigma burden and factors amenable to targeted interventions. As individual stigma-reductions interventions cannot be performed isolated from HIV-related stigma and discrimination in society, a key challenge is to intensify anti-stigma interventions also on the societal level.
... HIV can significantly impact both the physical and emotional well-being of individuals (Rzeszutek et al., 2021). Engaging in self-care practices can play a crucial role in improving treatment adherence, managing HIV symptoms, and enhancing the overall quality of life (Mehraeen et al., 2018;Mehraeen et al., 2020). ...
... Without the emotional and psychological support provided by these groups, individuals may experience higher levels of stress, anxiety, and depression, which can adversely affect their treatment adherence and overall health outcomes [7,8]. Social isolation and stigma can be more pronounced, leading to a decreased quality of life [9][10][11]. Moreover, inadequate support may result in poor disease management, higher rates of opportunistic infections, and ultimately, an increased risk of morbidity and mortality among PLHIV [12]. ...
Article
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In the realm of HIV care, support groups play a pivotal role by bringing together individuals living with HIV to share experiences and receive guidance from healthcare professionals. These groups are renowned for their substantial benefits, including improving emotional well-being, enhancing treatment adherence, and fostering a strong sense of community. However, despite these advantages, there is a notable gap in Ethiopia regarding concrete evidence of their impact on key treatment outcomes. This study aims to bridge this gap by exploring how support group care influences viral suppression rates among HIV patients. The study was conducted among 259 HIV-positive individuals on ART using the EPHIA survey, employing a two-stage, stratified sampling design across urban areas in nine regions and two city administrations. Data analysis was performed using STATA version 17, and multicollinearity was assessed (VIF = 1.07). A multivariate logistic regression model was fitted, with a p-value of ≤ 0.05 considered statistically significant. Results showed that 25.12% of participants utilized HIV support groups. Those who participated in support groups were 3.14 times more likely to achieve viral load suppression compared to non-participants (AOR = 3.14, 95% CI: 1.35–6.30). This study highlights that HIV support groups significantly boost viral suppression rates, underscoring the importance of integrating these groups into standard treatment protocols. These findings underline the need for continued research to assess long-term outcomes and further optimize the effectiveness of support group care in enhancing HIV treatment outcomes.
... Older individuals have been shown to have a stronger negative relationship between stigma and well-being (Emlet et al., 2015;C. Logie & Gadalla, 2009;Rzeszutek et al., 2021). People identifying as non-heterosexual have been shown to have worse medication adherence, depression, resilience, and quality of life (C. ...
Article
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Determinants of health are important drivers of health states, yet there is little work examining their role in the relationship between HIV stigma and health. This study uses moderation analysis to examine how determinants of health affect the relationship between enacted, internalized, and anticipated stigma and mental health. Quantitative data was collected on 337 participants in Ontario, Canada at baseline (t1) between August 2018 and September 2019 and at follow-up (t2) between February 2021 and October 2021. Separate moderation models were created with each determinant of health (age, gender, sexual orientation, ethnicity, geographic region, education, employment, and basic needs) acting as the moderator between types of stigma at t1 and mental health at t2. Age was a significant moderator for the relationship between internalized and enacted stigma at t1 and mental health at t2. Region was a moderator for enacted and anticipated stigma and mental health. Sexual orientation was a moderator for anticipated stigma and mental health. Lastly, having basic needs was a moderator for enacted and anticipated stigma and mental health. Our findings suggest that intervention strategies may be more effective by incorporating supports for these determinants of health in addition to stigma reduction to improve mental health.
Article
Although the biomedical advancements in HIV treatment have improved the original prognosis of the illness, people living with HIV (PLHIV) continue to encounter psychosocial challenges that impact their quality of life (QoL), including HIV-stigma and social connectedness. The present study investigates how different types of HIV-related stigma, as per the Conceptual Model of Perceived Stigma, respectively relate to QoL in the context of social connectedness in PLHIV. A total of 213 PLHIV attending a tertiary HIV clinic in Sydney Australia, completed questionnaires assessing HIV-related stigma, social connectedness, and QoL. After controlling for illness duration, the results revealed that overall HIV-related stigma and social connectedness were predictors of reduced QoL. Specifically, negative self-image, one of the four stigma types, was associated with decreased QoL, while personalized stigma, concerns about public attitudes, and disclosure concerns were not significant predictors. Furthermore, social connectedness partially mediated the relationship between negative self-image and QoL. This study enhances understanding of the impact of various forms of HIV-related stigma in an Australian cohort, including the role of social relationships, providing novel insights for clinical interventions.
Article
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Context and Aim: Adherence to antiretroviral treatment (ART) among men who have sex with men (MSM) living with HIV poses a public health challenge. Although studies in developed countries emphasize the role of psychosocial factors in ART adherence, there is limited research on this association among Brazilian MSM living with HIV. This study examined the impact of depression, anxiety, internalized homonegativity, and HIV-related stigma on ART adherence in a sample of this population. Method: A cross-sectional study recruited 43 MSM living with HIV (Mage = 34.93, SD = 7.90) through social media. Instruments included sociodemographic and clinical questionnaires, the Questionnaire for Assessment of Adherence to Antiretroviral Treatment, the Beck Depression Scale, the Trait-State Anxiety Inventory, the Internalized Homophobia Scale, and the HIV Stigmatization Scale. Results: Twelve participants (27.9%) showed inadequate ART adherence, and 18 (41.8%) reported signs and symptoms of depression at clinical level. Depression was negatively and moderately correlated with ART adherence. HIV-related stigma was positively and moderately correlated with depression, trait anxiety, and homonegativity. Depression significantly impacted ART adherence, explaining 13.4% of the variance. Conclusions: Our results highlight the need for regular depression screening and affirmative interventions to support MSM living with HIV, addressing stigma, and promoting adherence to ART.
Article
People living with HIV (PLHIV) in Ecuador experience challenges including discrimination, violence, and limited access to healthcare, which impacts their mental health and well-being. However, research shows that PLHIV also rely on social resources to foster resilience. In the Ecuadorian context, there is no literature exploring these narratives, which results in a lack of qualitative data to improve the reality of PLHIV in the country. To gain a deeper understanding of these stories, 15 semi-structured interviews were undertaken (15 verbatim hours) within the context of a peer- and professional-led support group for PLHIV and were analyzed through a thematic approach based on Skovdal and Daniel’s conceptual framework on resilience and adversity. Findings suggest that PLHIV face multifaceted challenges across the home, community, and political-economy spheres. Families and communities can elicit pain and fear, leading individuals to avoid discussing their diagnosis due to ongoing rejection. Further, discrimination perpetuated within the public health sector, as well as societal violence, exacerbates adversity. Nevertheless, participants stress the indispensable role of family support, community networks, and accessible healthcare in fostering resilience. Specifically, support, emotional reassurance, and willingness to learn enabled PLHIV to build resilience. These findings emphasize the need for approaches that counter discrimination, enhance well-being, ensure integral and intersectional healthcare access, and promote knowledge around HIV.
Article
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HIV stigma remains a barrier to good health and understanding how social support may reduce the negative impact of stigma on health may help with designing stigma interventions. This study aims to understand how different types of social support may moderate or change the nature of the relationship between stigma and mental health. We recruited 327 participants to complete the People Living with HIV Stigma Index at baseline (t1) between August 2018 and September 2019 and at follow-up (t2) between February 2021 and October 2021. Separate moderation models were created with different types of social support (emotional/informational, tangible, affectionate, positive social interaction) as moderators, baseline stigma (internalized, enacted, anticipated) as the antecedent, and mental health (t2) as the outcome. Emotional/informational support was a significant moderator for the relationship between enacted (b = -2.12, 95% CI: -3.73, -0.51), internalized (b = -1.72, 95% CI: -3.24, -0.20), and anticipated (b = -2.59, 95% CI: -4.59, -0.60) stigma at t1 and mental health at t2. Tangible support was a significant moderator for internalized stigma (b = -1.54, 95% CI: -2.74, -0.35). Lastly, positive social interaction was a significant moderator for internalized (b = -1.38, 95% CI: -2.71, -0.04) and anticipated stigma (b = -2.14, 95% CI: -3.93, -0.36). In general, the relationship between social support and better mental health was stronger for participants with low stigma. Intervention strategies aimed at both stigma reduction and boosting social supports with different functions may be important for improving the mental health of people living with HIV.
Article
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Background: HIV-related stigma is associated with worse health outcomes and lower adherence to antiretroviral therapy. There is limited data on the stigma faced by Latin American cisgender women, although they are among the populations most affected by HIV. This study aims to provide insight into the Stigma Index Brazil, with the objective of estimating the prevalence of HIV-related stigma among cisgender women in Brazil and to investigate the role of low socioeconomic status in stigma experience. Methods: This is a cross-sectional community-based study. A total of 30 people with HIV were trained to recruit participants from their peer networks; 1,768 people with HIV from all regions of Brazil participated in the study, of which 566 participants were cisgender women. We used the Stigma Index, an instrument that assesses global trends in HIV-related stigma from the perspective of people with HIV. Results: Approximately 70% of participants reported some form of HIV-related stigma. The most prevalent forms were discriminatory comments or gossiping (51.26%) and verbal harassment (30.99%). More than 20% experienced any health care related HIV-stigma in the last 12 months, the most frequent being the avoidance of physical contact (10.02%). Women in social vulnerability faced more stigma compared to the group without social vulnerability, both in general contexts (75.79% vs 64.32%; χ2 = 8.67, p < 0.05) and in healthcare contexts (24.12% vs 16.02%; χ2 = 4.06, p < 0.05). Conclusion: We found a high prevalence of stigma associated with HIV faced by Brazilian women from all regions of the country, both in everyday life and in healthcare contexts. Evidence-based interventions to reduce stigma in the general population, and specific mental health care aimed at women with HIV in Brazil, especially among those with greater socioeconomic vulnerability, are urgent.