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Interpersonal Mechanisms Contributing to the Association Between HIV-Related Internalized Stigma and Medication Adherence

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Abstract

Previous research suggests that people living with HIV (PLWH) sometimes internalize HIV-related stigma existing in the community and experience feelings of inferiority and shame due to their HIV status, which can have negative consequences for treatment adherence. PLWH’s interpersonal concerns about how their HIV status may affect the security of their existing relationships may help explain how internalized stigma affects adherence behaviors. In a cross-sectional study conducted between March 2013 and January 2015 in Birmingham, AL, 180 PLWH recruited from an outpatient HIV clinic completed previously validated measures of internalized stigma, attachment styles, and concern about being seen while taking HIV medication. Participants also self-reported their HIV medication adherence. Higher levels of HIV-related internalized stigma, attachment-related anxiety (i.e., fear of abandonment by relationship partners), and concerns about being seen by others while taking HIV medication were all associated with worse medication adherence. The effect of HIV-related internalized stigma on medication adherence was mediated by attachment-related anxiety and by concerns about being seen by others while taking HIV medication. Given that medication adherence is vitally important for PLWH to achieve long-term positive health outcomes, understanding interpersonal factors affecting medication adherence is crucial. Interventions aimed at improving HIV treatment adherence should address interpersonal factors as well as intrapersonal factors.

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Notes

  1. Participants without missing data did not differ from participants with missing data on any of the study variables (all p values >.11), except that participants without missing data were older (t = 2.56, p = .01).

  2. The interaction of avoidance and anxiety did not show a significant effect on medication adherence.

  3. The indirect effect was also significant when controlling for avoidance.

  4. Concern about being seen taking HIV medication was not normally distributed (Kolmogorov–Smirnov z = 2.20, p < .05). However, a regression analysis using bootstrapping (with 1000 bootstrapping samples), which does not require a normal distribution, yielded very similar results.

References

  1. Centers for Disease Control and Prevention. HIV surveillance report, 2012.

  2. Reif SS, Whetten K, Wilson ER, McAllaster C, Pence BW, Legrand S, et al. HIV/AIDS in the Southern USA: a disproportionate epidemic. AIDS Care. 2014;26(3):351–9.

    Article  PubMed  Google Scholar 

  3. Baunach DM, Burgess EO. HIV/AIDS prejudice in the American deep south. Sociol Spectr. 2013;33(2):175–95.

    Article  Google Scholar 

  4. Heckman TG, Somlai A, Peters J, Walker J, Otto-Salaj L, Galdabini C, et al. Barriers to care among persons living with HIV/AIDS in urban and rural areas. AIDS Care. 1998;10(3):365–75.

    Article  CAS  PubMed  Google Scholar 

  5. Reif S, Golin C, Smith S. Barriers to accessing HIV/AIDS care in North Carolina: rural and urban differences. AIDS Care. 2005;17(5):558–65.

    Article  CAS  PubMed  Google Scholar 

  6. Stringer KL, Turan B, McCormick L, Durojaiye M, Nyblade L, Kempf M-C, et al. HIV-related stigma among healthcare providers in the deep south. AIDS Behav. 2016;20(1):115–25.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Harrigan PR, Hogg RS, Dong WW, Yip B, Wynhoven B, Woodward J, et al. Predictors of HIV drug-resistance mutations in a large antiretroviral-naive cohort initiating triple antiretroviral therapy. J Infect Dis. 2005;191(3):339–47.

    Article  CAS  PubMed  Google Scholar 

  8. Mannheimer S, Matts J, Telzak E, Chesney M, Child C, Wu A, et al. Quality of life in HIV-infected individuals receiving antiretroviral therapy is related to adherence. AIDS Care. 2005;17(1):10–22.

    Article  CAS  PubMed  Google Scholar 

  9. Beer L, Fagan JL, Garland P, Valverde EE, Bolden B, Brady KA, et al. Medication-related barriers to entering HIV care. AIDS Patient Care STDS. 2012;26(4):214–21.

    PubMed  PubMed Central  Google Scholar 

  10. Beer L, Oster AM, Mattson CL, Skarbinski J. Disparities in HIV transmission risk among HIV-infected black and white men who have sex with men, United States, 2009. AIDS. 2014;28(1):105–14.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Centers for Disease Control and Prevention. Monitoring selected national HIV prevention and care objectives by using HIV surveillance data—United States and 6 US dependent areas—2010. HIV surveillance supplemental report. 2012;17(3).

  12. Lichtenstein B. Stigma as a barrier to treatment of sexually transmitted infection in the American deep south: issues of race, gender and poverty. Soc Sci Med. 2003;57(12):2435–45.

    Article  PubMed  Google Scholar 

  13. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;2001:363–85.

    Article  Google Scholar 

  14. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS Behav. 2009;13(6):1160–77.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Mahajan AP, Sayles JN, Patel VA, Remien RH, Ortiz D, Szekeres G, et al. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS. 2008;22:S67–79.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Link BG, Phelan JC. Stigma and its public health implications. Lancet. 2006;367(9509):528–9.

    Article  PubMed  Google Scholar 

  17. Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17(5):1785–95.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Goffman E. Stigma; notes on the management of spoiled identity. Englewood Cliffs: Prentice-Hall; 1963.

    Google Scholar 

  19. Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24(6):518–29.

    Article  CAS  PubMed  Google Scholar 

  20. Cox WT, Abramson LY, Devine PG, Hollon SD. Stereotypes, prejudice, and depression the integrated perspective. Perspect Psychol Sci. 2012;7(5):427–49.

    Article  PubMed  Google Scholar 

  21. DiIorio C, McCarty F, Depadilla L, Resnicow K, Holstad MM, Yeager K, et al. Adherence to antiretroviral medication regimens: a test of a psychosocial model. AIDS Behav. 2009;13(1):10–22.

    Article  PubMed  Google Scholar 

  22. Rao D, Feldman BJ, Fredericksen RJ, Crane PK, Simoni JM, Kitahata MM, et al. A structural equation model of HIV-related stigma, depressive symptoms, and medication adherence. AIDS Behav. 2012;16(3):711–6.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Sayles JN, Ryan GW, Silver JS, Sarkisian CA, Cunningham WE. Experiences of social stigma and implications for healthcare among a diverse population of HIV positive adults. J Urban Health. 2007;84:814–28.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Turan B, Smith W, Cohen MH, Wilson TE, Adimora AA, Merenstein D, et al. Mechanisms for the negative effects of internalized HIV-related stigma on ART adherence in women: the roles of social isolation and depression. JAIDS (in press).

  25. Kalichman SC, Pope H, White D, Cherry C, Amaral CM, Swetzes C, et al. Association between health literacy and HIV treatment adherence: further evidence from objectively measured medication adherence. J Int Assoc Physicians AIDS Care (JIAPAC). 2008;7(6):317–23.

    Article  Google Scholar 

  26. Phillips KD, Moneyham L, Tavakoli A. Development of an instrument to measure internalized stigma in those with HIV/AIDS. Issues Ment Health Nurs. 2011;32(6):359–66.

    Article  PubMed  Google Scholar 

  27. Sayles JN, Wong MD, Kinsler JJ, Martins D, Cunningham WE. The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS. J Gen Intern Med. 2009;24(10):1101–8.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Vyavaharkar M, Moneyham L, Corwin S, Saunders R, Annang L, Tavakoli A. Relationships between stigma, social support, and depression in HIV-infected African American women living in the rural Southeastern United States. J Assoc Nurses AIDS Care. 2010;21(2):144–52.

    Article  PubMed  Google Scholar 

  29. Takada S, Weiser SD, Kumbakumba E, Muzoora C, Martin JN, Hunt PW, et al. The dynamic relationship between social support and HIV-related stigma in rural Uganda. Ann Behav Med. 2014;48(1):26–37.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Mikulincer M, Shaver PR. Attachment in adulthood: Structure, dynamics, and change. New York: Guilford; 2007.

    Google Scholar 

  31. Bowlby J. A secure base: parent-child attachment and healthy human behavior. New York: Basic Books; 1988.

    Google Scholar 

  32. Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes WS, editors. Attachment theory and close relationships. New York: Guilford Press; 1998. p. 46–76.

    Google Scholar 

  33. Turan B, Osar Z, Turan JM, Ilkova H, Damci T. Dismissing attachment and outcome in diabetes: the mediating role of coping. J Soc Clin Psychol. 2003;22(6):607–26.

    Article  Google Scholar 

  34. Bennett JK, Fuertes JN, Keitel M, Phillips R. The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment. Patient Educ Couns. 2011;85(1):53–9.

    Article  PubMed  Google Scholar 

  35. Davila J, Karney B, Bradbury T. Attachment change processes in the early years of marriage. J Pers Soc Psychol. 1999;76(5):783–802.

    Article  CAS  PubMed  Google Scholar 

  36. Kirkpatrick LA, Hazan C. Attachment styles and close relationships: a four-year prospective study. Pers Relatsh. 1994;1(2):123–42.

    Article  Google Scholar 

  37. Feeney JA, Noller P. Attachment style and romantic love: relationship dissolution. Aust J Psychol. 1992;44(2):69–74.

    Article  Google Scholar 

  38. Ruvolo AP, Fabin LA, Ruvolo CM. Relationship experiences and change in attachment characteristics of young adults: the role of relationship breakups and conflict avoidance. Pers Relatsh. 2001;8(3):265–81.

    Article  Google Scholar 

  39. Davila J, Cobb RJ. Predicting change in self-reported and interviewer-assessed adult attachment: tests of the individual difference and life stress models of attachment change. Pers Soc Psychol Bull. 2003;29(7):859–70.

    Article  PubMed  Google Scholar 

  40. Davila J, Cobb RJ. Predictors of change in attachment security during adulthood. In: Simpson JA, Rholes WS, editors. Adult attachment: theory, research, and clinical implications. New York: Guilford Publications; 2004. p. 133–56.

    Google Scholar 

  41. Davila J, Sargent E. The meaning of life (events) predicts changes in attachment security. Pers Soc Psychol Bull. 2003;29(11):1383–95.

    Article  PubMed  Google Scholar 

  42. Boehme AK, Davies SL, Moneyham L, Shrestha S, Schumacher J, Kempf M-C. A qualitative study on factors impacting HIV care adherence among postpartum HIV-infected women in the rural southeastern USA. AIDS Care. 2014;26(5):574–81.

    Article  PubMed  Google Scholar 

  43. Rintamaki LS, Davis TC, Skripkauskas S, Bennett CL, Wolf MS. Social stigma concerns and HIV medication adherence. AIDS Patient Care STDS. 2006;20(5):359–68.

    Article  PubMed  Google Scholar 

  44. Turan B, Fazeli P, Raper JL, Mugavero MJ, Johnson MO. Social support and moment-to-moment changes in treatment self-efficacy in men living with HIV: psychosocial moderators and clinical outcomes. Health Psychol (in press).

  45. Feldman B, Fredericksen R, Crane P, Safren S, Mugavero M, Willig JH, et al. Evaluation of the single-item self-rating adherence scale for use in routine clinical care of people living with HIV. AIDS Behav. 2013;17(1):307–18.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Lu M, Safren SA, Skolnik PR, Rogers WH, Coady W, Hardy H, et al. Optimal recall period and response task for self-reported HIV medication adherence. AIDS Behav. 2008;12(1):86–94.

    Article  PubMed  Google Scholar 

  47. Thompson MA, Mugavero MJ, Amico KR, Cargill VA, Chang LW, Gross R, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med. 2012;156(11):817–33.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Bunn JY, Solomon SE, Miller C, Forehand R. Measurement of stigma in people with HIV: a reexamination of the HIV Stigma Scale. AIDS Educ Prev. 2007;19(3):198–208.

    Article  PubMed  Google Scholar 

  49. DeMasi RA, Graham NM, Tolson JM, Pham SV, Capuano GA, Fisher RL, et al. Correlation between self-reported adherence to highly active antiretroviral therapy (HAART) and virologic outcome. Adv Ther. 2001;18(4):163–73.

    Article  CAS  PubMed  Google Scholar 

  50. Chesney MA, Ickovics JR, Chambers DB, Gifford AL, Neidig J, Zwickl B, et al. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: the AACTG adherence instruments. Patient Care Committee & Adherence Working Group of the Outcomes Committee of the Adult AIDS Clinical Trials Group (AACTG). AIDS Care. 2000;12(3):255–66.

    Article  CAS  PubMed  Google Scholar 

  51. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: Guilford Press; 2013.

    Google Scholar 

  52. Cameron JJ, Finnegan H, Morry MM. Orthogonal dreams in an oblique world: a meta-analysis of the association between attachment anxiety and avoidance. J Res Personal. 2012;46(5):472–6.

    Article  Google Scholar 

  53. Knight MT, Wykes T, Hayward P. Group treatment of perceived stigma and self-esteem in schizophrenia: a waiting list trial of efficacy. Behav Cogn Psychother. 2006;34(03):305–18.

    Article  Google Scholar 

  54. Heijnders M, Van Der Meij S. The fight against stigma: an overview of stigma-reduction strategies and interventions. Psychol Health Med. 2006;11(3):353–63.

    Article  PubMed  Google Scholar 

  55. Crepaz N, Tungol-Ashmon MV, Vosburgh HW, Baack BN, Mullins MM. Are couple-based interventions more effective than interventions delivered to individuals in promoting HIV protective behaviors? A meta-analysis. AIDS Care. 2015;2015:1–6.

    Google Scholar 

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Acknowledgments

This research was supported by the University of Alabama at Birmingham (UAB) Center for AIDS Research CFAR, an NIH funded program (P30 AI027767) that was made possible by the following institutes: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIDDK, NIGMS, and OAR. The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health (NIH). We would like to thank Maria Lechtreck, Wesley Browning, Christy Thai, and all the research assistants for their help in data collection. This article is based in part on an undergraduate honors thesis conducted by C. Blake Helms under the supervision of Dr. Bulent Turan at the University of Alabama at Birmingham.

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Authors and Affiliations

  1. The Department of Psychology, University of Alabama at Birmingham, 415 Campbell Hall, Birmingham, AL, 35294-1170, USA

    C. Blake Helms, Ghislaine Atkins, Olivio J. Clay & Bulent Turan

  2. Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL, USA

    Janet M. Turan

  3. Department of Family, Community and Health Systems and Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, USA

    Mirjam-Colette Kempf

  4. The Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA

    James L. Raper & Michael J. Mugavero

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  1. C. Blake Helms
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Correspondence to Bulent Turan.

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Blake Helms, C., Turan, J.M., Atkins, G. et al. Interpersonal Mechanisms Contributing to the Association Between HIV-Related Internalized Stigma and Medication Adherence. AIDS Behav 21, 238–247 (2017). https://doi.org/10.1007/s10461-016-1320-2

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