According to data published in AIDS, HIV stigma may contribute to African American women in the United States being more likely to experience poor HIV-related health outcomes.
Sociodemographic and psychosocial data were collected during a randomized trial of an intervention to reduce HIV stigma conducted in Chicago, Illinois, and Birmingham, Alabama. The trial enrolled 234 African American women in HIV care in both cities and included up to 6 study visits over a period of 14 months. Viral load data were also extracted from medical records during the study period.
Generalized linear mixed effects models were used to estimate associations between overall, internalized, and enacted HIV stigma and viral load over time. Results found stigma to be significantly associated with subsequent viral load. In fact, one model demonstrated that each standard deviation increase in overall HIV stigma was linked with an increase in log mean viral load (adjusted β coefficient =0.24, P =.005). A submodel of these data showed that the between-subject effects of HIV stigma were associated with log mean viral load (adjusted β coefficient= 0.39; 95% CI, 0.11-0.67) and viral suppression (adjusted odds ratio 0.58; 95% CI, 0.40-0.85); however, within-subject effects (adjusted β= 0.34; P =.005) did not demonstrate the same association.
A second model demonstrated an association between log mean viral load and viral suppression and enacted stigma (adjusted β coefficient=0.44; 95% CI, 0.24-0.64 and adjusted odds ratio, 0.62; 95% CI, 0.43-0.90, respectively); however, this was not found for internalized stigma.
In addition, overall HIV stigma was shown to be negatively associated with social support in the first round of data analysis; however, in the second round, results showed that independent of stigma, social support was not associated with log mean viral load. The effect of overall HIV stigma on log mean viral load mediated by social support was approximated at 19%; however, secondary analysis found this to be nonstatistically significant. Depressive symptoms were not found to be statistically significant mediators.
Investigators highlighted several study limitations including that almost half of the viral load outcomes were missing, because many visits were not followed by measures of eligible viral loads. Steps were taken to avoid bias and loss of efficiency that may result from missing data, such as multiple imputation in the analysis. In addition, several factors known to be strongly associated with viral load, including alcohol/substance use and homelessness/housing insecurity, could not be adjusted for. Adjustments for possible observed or unobserved time varying confounders were also not made.
Further work is needed to confirm the direction of causality between HIV stigma and viral load and whether stigmatization by specific sources such as family members or healthcare workers is especially detrimental. The investigators also noted that, “this was a secondary analysis of data from a sample of women on treatment who participated in a group-based stigma reduction intervention,” and therefore may not be representative of the broader population of African American women living with HIV.
Researchers concluded that the study, “indicates that ongoing experiences of HIV stigma may have negative effects on viral load in this population over relatively short periods of time,” and this does not appear to be mediated by social support or depressive symptoms. Investigators therefore recommended that to ensure that interventions aimed at reducing stigma among this population have a beneficial impact on health, their focus may need to be broadened to target the source of stigma.
Kemp CG, Lipira L, Huh D, et al. HIV stigma and viral load among African-American women receiving treatment for HIV. AIDS. 2019;33:1511-1519.