Pathways From HIV-Related Stigma, Racial Discrimination, and Gender Discrimination to HIV Treatment Outcomes Among Women Living With HIV in Canada: Longitudinal Cohort Findings.
Journal
Journal of acquired immune deficiency syndromes (1999)
ISSN: 1944-7884
Titre abrégé: J Acquir Immune Defic Syndr
Pays: United States
ID NLM: 100892005
Informations de publication
Date de publication:
01 10 2023
01 10 2023
Historique:
received:
06
11
2022
accepted:
21
04
2023
medline:
15
9
2023
pubmed:
27
6
2023
entrez:
27
6
2023
Statut:
ppublish
Résumé
HIV-related stigma, gender discrimination, and racial discrimination harm mental health and hamper HIV treatment access for women living with HIV. Maladaptive coping strategies, such as substance use, can further worsen HIV treatment outcomes, whereas resilience can improve HIV outcomes. We examined resilience and depression as mediators of the relationship between multiple stigmas and HIV treatment outcomes among women living with HIV. Ontario, British Columbia, and Quebec, Canada. We conducted a longitudinal study with 3 waves at 18-month intervals. We used structural equation modeling to test the associations of multiple stigmas (HIV-related stigma, racial discrimination, and gender discrimination) or an intersectional construct of all 3 stigmas at wave 1 on self-reported HIV treatment cascade outcomes (≥95% antiretroviral treatment [ART] adherence, undetectable viral load) at wave 3. We tested depression and resilience at wave 2 as potential mediators and adjusted for sociodemographic factors. There were 1422 participants at wave 1, half of whom were Black (29%) or Indigenous (20%). Most participants reported high ART adherence (74%) and viral suppression (93%). Racial discrimination was directly associated with having a detectable viral load, while intersectional stigma was directly associated with lower ART adherence. Resilience mediated associations between individual and intersectional stigmas and HIV treatment cascade outcomes, but depression did not. Racial discrimination was associated with increased resilience, while intersectional and other individual stigmas were associated with reduced resilience. Race, gender and HIV-related stigma reduction interventions are required to address intersectional stigma among women living with HIV. Including resilience-building activities in these interventions may improve HIV treatment outcomes.
Sections du résumé
BACKGROUND
HIV-related stigma, gender discrimination, and racial discrimination harm mental health and hamper HIV treatment access for women living with HIV. Maladaptive coping strategies, such as substance use, can further worsen HIV treatment outcomes, whereas resilience can improve HIV outcomes. We examined resilience and depression as mediators of the relationship between multiple stigmas and HIV treatment outcomes among women living with HIV.
SETTING
Ontario, British Columbia, and Quebec, Canada.
METHODS
We conducted a longitudinal study with 3 waves at 18-month intervals. We used structural equation modeling to test the associations of multiple stigmas (HIV-related stigma, racial discrimination, and gender discrimination) or an intersectional construct of all 3 stigmas at wave 1 on self-reported HIV treatment cascade outcomes (≥95% antiretroviral treatment [ART] adherence, undetectable viral load) at wave 3. We tested depression and resilience at wave 2 as potential mediators and adjusted for sociodemographic factors.
RESULTS
There were 1422 participants at wave 1, half of whom were Black (29%) or Indigenous (20%). Most participants reported high ART adherence (74%) and viral suppression (93%). Racial discrimination was directly associated with having a detectable viral load, while intersectional stigma was directly associated with lower ART adherence. Resilience mediated associations between individual and intersectional stigmas and HIV treatment cascade outcomes, but depression did not. Racial discrimination was associated with increased resilience, while intersectional and other individual stigmas were associated with reduced resilience.
CONCLUSION
Race, gender and HIV-related stigma reduction interventions are required to address intersectional stigma among women living with HIV. Including resilience-building activities in these interventions may improve HIV treatment outcomes.
Identifiants
pubmed: 37368938
doi: 10.1097/QAI.0000000000003241
pii: 00126334-990000000-00256
doi:
Substances chimiques
Anti-Retroviral Agents
0
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
116-123Subventions
Organisme : CIHR
ID : CTN 262
Pays : Canada
Informations de copyright
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The authors have no funding or conflicts of interest to disclose.
Références
Public Health Agency of Canada. Estimates of HIV Incidence, Prevalence and Canada's Progress on Meeting the 90-90-90 HIV Targets—Canada.ca. Available at: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/summary-estimates-hiv-incidence-prevalence-canadas-progress-90-90-90.html . Accessed May 18, 2022.
Tapp C, Milloy MJ, Kerr T, et al. Female gender predicts lower access and adherence to antiretroviral therapy in a setting of free healthcare. BMC Infect Dis. 2011;11:86.
Statistics Canada. 2016 Census (Online), Ottawa, Ontario, Canada: Statistics Canada; 2016.
Haddad N, Robert A, Weeks A, et al. HIV in Canadasurveillance report, 2018. Can Commun Dis Rep. 2019;45:304–312.
Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. U Chic Legal Forum 1989;139:139–167.
Collins PH. Intersectionality's definitional dilemmas. Annu Rev Sociol. 2015;41:1–21.
Bowleg L. The problem with intersectional stigma and HIV equity research. Am J Public Health. 2022;112:S344–S346.
Berger MT. Workable Sisterhood: The Political Journey of Stigmatized Women with HIV/AIDS. Princeton, NJ: Princeton University Press; 2010.
Turan B, Hatcher AM, Weiser SD, et al. Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. Am J Public Health. 2017;107:863–869.
Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363–385.
Tsai AC, Weiser SD, Steward WT, et al. Evidence for the reliability and validity of the internalized aids-related stigma scale in rural Uganda. AIDS Behav. 2013;17:427–433.
Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6:309–319.
Pantelic M, Sprague L, Stangl AL. It's not “all in your head”: critical knowledge gaps on internalized HIV stigma and a call for integrating social and structural conceptualizations. BMC Infect Dis. 2019;19:1–8.
Brown MJ, Serovich JM, Kimberly JA, et al. Psychological reactance and HIV-related stigma among women living with HIV. AIDS Care. 2016;28:745–749.
Stangl AL, Earnshaw VA, Logie CH, et al. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med. 2019;17:31.
Logie CH, James L, Tharao W, et al. HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med. 2011;8:e1001124.
Katz IT, Ryu AE, Onuegbu AG, et al. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc. 2013;16(3 Suppl 2):18640.
Williams DR, Lawrence JA, Davis BA. Racism and health: evidence and needed research. Annu Rev Public Health. 2019;40:105–125.
Homan P. Structural sexism and health in the United States: a new perspective on health inequality and the gender system. Am Sociol Rev. 2019;84:486–516.
Paradies Y, Ben J, Denson N, et al. Racism as a determinant of health: a systematic review and meta-analysis. PLoS One. 2015;10:e0138511.
Shokoohi M, Bauer GR, Kaida A, et al. Substance use patterns among women living with HIV compared with the general female population of Canada. Drug Alcohol Depend. 2018;191:70–77.
Sen G, Östlin P, George A. Unequal, Unfair, Ineffective and Inefficient Gender Inequity in Health: Why It Exists and How We Can Change It. Sweden: Karolinska Instituet; 2007.
Kronfli N, Lacombe-Duncan A, Wang L, et al. Understanding the correlates of attrition associated with antiretroviral use and viral suppression among women living with HIV in Canada. AIDS Patient Care STDS. 2017;31:428–437.
Logie C, James L, Tharao W, et al. Associations between HIV-related stigma, racial discrimination, gender discrimination, and depression among HIV-positive African, Caribbean, and black women in Ontario, Canada. AIDS Patient Care STDS. 2013;27:114–122.
Dulin AJ, Dale SK, Earnshaw VA, et al. Resilience and HIV: a review of the definition and study of resilience. AIDS Care. 2018;30(suppl 5):S6–S17.
Dale SK, Safren SA. Resilience takes a village: Black women utilize support from their community to foster resilience against multiple adversities. AIDS Care. 2018;30(suppl 5):S18–S26.
Qiao S, Ingram L, Deal ML, et al. Resilience resources among African American women living with HIV in Southern United States. AIDS. 2019;33:S35–S44.
Logie CH, Wang Y, Kazemi M, et al. Exploring social ecological pathways from resilience to quality of life among women living with HIV in Canada. AIDS Care. 2018;30(suppl 5):S67–S75.
Poteat TC, Logie CH. A case for strengths-based approaches to addressing intersectional stigma in HIV research. Am J Public Health. 2022;112:S347–S349.
Logie CH, Earnshaw V, Nyblade L, et al. A scoping review of the integration of empowerment-based perspectives in quantitative intersectional stigma research. Glob Public Health. 2021;17:1451–1466.
Earnshaw VA, Smith LR, Chaudoir SR, et al. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17:1785–1795.
Turan JM, Elafros MA, Logie CH, et al. Challenges and opportunities in examining and addressing intersectional stigma and health. BMC Med. 2019;17:1–15.
Rice WS, Logie CH, Napoles TM, et al. Perceptions of intersectional stigma among diverse women living with HIV in the United States. Soc Sci Med. 2018;208:9–17.
DiIorio C, McCarty F, DePadilla L, et al. Adherence to antiretroviral medication regimens: a test of a psychosocial model. AIDS Behav. 2009;13:10–22.
Earnshaw VA, Bogart LM, Dovidio JF, et al. Stigma and racial/ethnic HIV disparities: moving toward resilience. Am Psychol. 2013;68:225–236.
Earnshaw VA, Lang SM, Lippitt M, et al. HIV stigma and physical health symptoms: do social support, adaptive coping, and/or identity centrality act as resilience resources? AIDS Behav. 2015;19:41–49.
Logie CH, Williams CC, Wang Y, et al. Adapting stigma mechanism frameworks to explore complex pathways between intersectional stigma and HIV-related health outcomes among women living with HIV in Canada. Soc Sci Med. 2019;232:129–138.
Davis K. Intersectionality as buzzword: a sociology of science perspective on what makes a feminist theory successful. Feminist Theor. 2008;9:67–85.
Andersson GZ, Reinius M, Eriksson LE, et al. Stigma reduction interventions in people living with HIV to improve health-related quality of life. Lancet HIV. 2020;7:e129–e140.
Relf MV, Holzemer WL, Holt L, et al. A review of the state of the science of HIV and stigma: context, conceptualization, measurement, interventions, gaps, and future priorities. J Assoc Nurses AIDS Care. 2021;32:392.
Wright K, Naar-King S, Lam P, et al. Stigma scale revised: reliability and validity of a brief measure of stigma for HIV+ youth. J Adolesc Health. 2007;40:96–98.
Krieger N, Smith K, Naishadham D, et al. Experiences of discrimination: validity and reliability of a self-report measure for population health research on racism and health. Soc Sci Med. 2005;61:1576–1596.
Zhang W, O'Brien N, Forrest JI, et al. Validating a shortened depression scale (10 item CES-D) among HIV-positive people in British Columbia, Canada. PLoS One. 2012;7:e40793.
Wagnild Gail M. The Resilience Scale User's Guide, for the US English Version of The Resilience Scale TM and The 14-item Resilience Scale TM (RS-14 TM). Billings, MT: Resilience Center; 2011.
Bartlett JA. Addressing the challenges of adherence. J Acquir Immune Defic Syndr. 2002;29:S2–S10.
Carter A, De Pokomandy A, Loutfy M, et al. Validating a self-report measure of HIV viral suppression: an analysis of linked questionnaire and clinical data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study. BMC Res Notes. 2017;10:1–7.
Nguyen TQ, Webb-Vargas Y, Koning IM, et al. Causal mediation analysis with a binary outcome and multiple continuous or ordinal mediators: simulations and application to an alcohol intervention. Struct Equ Model. 2016;23:368–383.
Kaplan D, Depaoli S. Bayesian Structural Equation Modeling. Handbook of Structural Equation Modeling. New York, NY: The Guilford Press; 2012.
Cain MK, Zhang Z. Fit for a Bayesian: an evaluation of PPP and DIC for structural equation modeling. Struct Equ Model. 2019;26:39–50.
Chapman Lambert C, Fazeli PL, Yigit I, et al. The mediating role of social support and resilience between HIV-related stigmas and patient activation among young black women living with HIV in the southern United States: a cross-sectional study. J Assoc Nurses AIDS Care. 2022;33:78–88.
Thomas Tobin CS, Erving CL, Barve A. Race and SES differences in psychosocial resources: implications for social stress theory. Soc Psychol Q. 2021;84:1–25.
Hatzenbuehler ML, Nolen-Hoeksema S, Dovidio J. How does stigma “get under the skin”? The mediating role of emotion regulation: research article. Psychol Sci. 2009;20:1282–1289.
Hempel S, Ferguson L, Bolshakova M, et al. Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol. BMJ Open. 2021;11:e053608.
Gottert A, McClair TL, Pulerwitz J, et al. What shapes resilience among people living with HIV? A multi-country analysis of data from the PLHIV Stigma Index 2.0. AIDS. 2020;34:S19–S31.
Saban KL, Motley D, Shawahin L, et al. Preliminary evidence for a race-based stress reduction intervention for Black women at risk for cardiovascular disease. Complement Ther Med. 2021;58:102710.
Turan B, Rice WS, Crockett KB, et al. Longitudinal association between internalized HIV stigma and antiretroviral therapy adherence for women living with HIV: the mediating role of depression. AIDS. 2019;33:571–576.
Rice WS, Turan B, Fletcher FE, et al. A mixed methods study of anticipated and experienced stigma in health care settings among women living with HIV in the United States. AIDS Patient Care STDS. 2019;33:184–195.
Hanass-Hancock J, Carpenter B, Myezwa H. The missing link: exploring the intersection of gender, capabilities, and depressive symptoms in the context of chronic HIV. Women Health. 2019;59:1212–1226.
McIntosh RC, Rosselli M. Stress and coping in women living with HIV: a meta-analytic review. AIDS Behav. 2012;16:2144–2159.
Robbertz AS, Ishiekwene MN, Hucks OL, et al. The impact of trauma on South African women with HIV: the role of anxiety and physical symptomology. Afr J AIDS Res. 2021;20:141–148.
Webster K, Carter A, Proulx-Boucher K, et al. Strategies for recruiting women living with human immunodeficiency virus in community-based research: lessons from Canada. Prog Community Health Partnersh. 2018;12:21–34.