AIDS and Behavior

, Volume 19, Issue 8, pp 1454–1459 | Cite as

Depressive Symptoms Mediate the Effect of HIV-Related Stigmatization on Medication Adherence Among HIV-Infected Men Who Have Sex with Men

  • Luke D. MitzelEmail author
  • Peter A. VanableEmail author
  • Jennifer L. Brown
  • Rebecca A. Bostwick
  • Shannon M. Sweeney
  • Michael P. Carey
Brief Report


This study tested the hypothesis that depressive symptoms would mediate the association of HIV-related stigma to medication adherence. We recruited HIV-infected men who have sex with men (MSM; N = 66; 66 % White, 23 % African-American) from an outpatient infectious disease clinic, and asked them to complete self-report measures. Mediational analyses showed that depressive symptoms fully mediated the association between HIV-related stigma and adherence. That is, stigma-related experiences were positively associated with depressive symptoms and negatively associated with adherence, and, in the final model, depressive symptoms remained a significant correlate of adherence while stigma did not. A test of the indirect effect of stigma on adherence through depressive symptoms was also significant (unstandardized b = −0.19; bootstrap 95 % CI −0.45 to −0.01). These results highlight the importance of treating depressive symptoms in interventions aiming to improve medication adherence among HIV-infected MSM.


Stigma Medication adherence Depressive symptoms MSM HIV 



This research was supported by NIMH Grant R21-MH65865, awarded to Peter Vanable. The authors thank the Infectious Disease Clinic staff and patients at SUNY Upstate Medical University for their support of this work. We also thank Larry Hammonds for his assistance in recruiting study participants.


  1. 1.
    Bhaskaran K, Hamouda O, Sannes M, et al. Changes in the risk of death after HIV seroconversion compared with mortality in the general population. JAMA. 2008;300(1):51–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Farnham PG, Gopalappa C, Sansom SL, et al. Updates of lifetime costs of care and quality-of-life estimates for HIV-infected persons in the United States: late versus early diagnosis and entry into care. J Acquir Immune Defic Syndr. 2013;64(2):183–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Mahajan AP, Sayles JN, Patel VA, et al. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS. 2008;22(Suppl 2):S67–79.PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Joint United Nations Programme on HIV/AIDS. AIDS epidemic update 2013 [updated 2013 November; cited 2014 August 14].
  5. 5.
    Fortenberry JD, McFarlane M, Bleakley A, et al. Relationships of stigma and shame to gonorrhea and HIV screening. Am J Public Health. 2002;92(3):378–81.PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Rao D, Kekwaletswe TC, Hosek S, Martinez J, Rodriguez F. Stigma and social barriers to medication adherence with urban youth living with HIV. AIDS Care. 2007;19(1):28–33.PubMedCrossRefGoogle Scholar
  7. 7.
    Stutterheim SE, Shiripinda I, Bos AE, et al. HIV status disclosure among HIV-positive African and Afro-Caribbean people in the Netherlands. AIDS Care. 2011;23(2):195–205.PubMedCrossRefGoogle Scholar
  8. 8.
    Logie C, Gadalla TM. Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care. 2009;21(6):742–53.PubMedCrossRefGoogle Scholar
  9. 9.
    Hatzenbuehler ML, O’Cleirigh C, Mayer KH, Mimiaga MJ, Safren SA. Prospective associations between HIV-related stigma, transmission risk behaviors, and adverse mental health outcomes in men who have sex with men. Ann Behav Med. 2011;42(2):227–34.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Smith R, Rossetto K, Peterson BL. A meta-analysis of disclosure of one’s HIV-positive status, stigma and social support. AIDS Care. 2008;20(10):1266–75.PubMedCrossRefGoogle Scholar
  11. 11.
    Naughton JD, Vanable PA. HIV stigmatization among healthcare providers: review of the evidence and implications for HIV care. In: Liamputtong P, editor. Stigma, discrimination and living with HIV/AIDS: a cross-cultural perspective. New York, NY: Springer; 2013.Google Scholar
  12. 12.
    Sweeney SM, Vanable PA. Impact of HIV-related stigma on medication adherence in HIV-positive individuals. Manuscript submitted for publication; 2014.Google Scholar
  13. 13.
    Tilahun HA, Mariam DH, Tsui AO. Effect of perceived stigma on adherence to highly active antiretroviral therapy and self-confidence to take medication correctly in Addis Ababa, Ethiopia. J HIV/AIDS Soc Serv. 2012;11(4):346–62.CrossRefGoogle Scholar
  14. 14.
    Sabin LL, Desilva MB, Hamer DH, et al. Barriers to adherence to antiretroviral medications among patients living with HIV in southern China: a qualitative study. AIDS Care. 2008;20(10):1242–50.PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6(4):309–19.CrossRefGoogle Scholar
  16. 16.
    Vanable PA, Carey MP, Blair DC, Littlewood RA. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behav. 2006;10(5):473–82.PubMedCentralPubMedCrossRefGoogle Scholar
  17. 17.
    Onyebuchi-Iwudibia O, Brown A. HIV and depression in Eastern Nigeria: the role of HIV-related stigma. AIDS Care. 2014;26(5):653–7.PubMedCrossRefGoogle Scholar
  18. 18.
    Uthman OA, Magidson JF, Safren SA, Nachega JB. Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: a systematic review and meta-analysis. Curr HIV/AIDS Rep. 2014;11(3):291–307.PubMedCrossRefGoogle Scholar
  19. 19.
    Rao D, Feldman BJ, Fredericksen RJ, et al. A structural equation model of HIV-related stigma, depressive symptoms, and medication adherence. AIDS Behav. 2012;16(3):711–6.PubMedCentralPubMedCrossRefGoogle Scholar
  20. 20.
    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.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    DiIorio C, McCarty F, Depadilla L, et al. Adherence to antiretroviral medication regimens: a test of a psychosocial model. AIDS Behav. 2009;13(1):10–22.PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Centers for Disease Control and Prevention. Estimated HIV incidence in the United States, 2007–2010. HIV Surveill Suppl Rep. 2012;17(4):1–26.Google Scholar
  23. 23.
    Heckman TG. The chronic illness quality of life (CIQOL) model: explaining life satisfaction in people living with HIV disease. Health Psychol. 2003;22(2):140–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Heckman TG, Somlai AM, Kalichman SC, Franzoi SL, Kelly JA. Psychosocial differences between urban and rural people living with HIV/AIDS. J Rural Health. 1998;14(2):138–45.PubMedCrossRefGoogle Scholar
  25. 25.
    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.PubMedCentralPubMedCrossRefGoogle Scholar
  26. 26.
    Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.CrossRefGoogle Scholar
  27. 27.
    US Department of Health and Human Services. CES-D scale. Bethesda, MD: US Department of Health and Human Services and National Institute of Health; 2004.Google Scholar
  28. 28.
    Reisner SL, Mimiaga MJ, Skeer M, et al. Clinically significant depressive symptoms as a risk factor for HIV infection among black MSM in Massachusetts. AIDS Behav. 2009;13(4):798–810.PubMedCentralPubMedCrossRefGoogle Scholar
  29. 29.
    Safren SA, Thomas BE, Mimiaga MJ, et al. Depressive symptoms and human immunodeficiency virus risk behavior among men who have sex with men in Chennai, India. Psychol Health Med. 2009;14(6):705–15.PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19(2):124–33.PubMedCrossRefGoogle Scholar
  31. 31.
    Chesney MA, Ickovics JR, Chambers DB, 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.PubMedCrossRefGoogle Scholar
  32. 32.
    Arnsten JH, Demas PA, Farzadegan H, et al. Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring. Clin Infect Dis. 2001;33(8):1417–23.PubMedCentralPubMedCrossRefGoogle Scholar
  33. 33.
    Thirumurthy H, Siripong N, Vreeman RC, et al. Differences between self-reported and electronically monitored adherence among patients receiving antiretroviral therapy in a resource-limited setting. AIDS. 2012;26(18):2399–403.PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behav Res Methods. 2008;40(3):879–91.PubMedCrossRefGoogle Scholar
  35. 35.
    Baron RM, Kenny DA. Moderator-mediator variables distinction in social psychological research: conceptual, strategic, and statistical considerations. JPSP. 1986;51(6):1173–82.Google Scholar
  36. 36.
    Dodeen HM. Effectiveness of valid mean substitution in treating missing data in attitude assessment. Assess Eval High Educ. 2003;28(5):505–13.CrossRefGoogle Scholar
  37. 37.
    Wohl AR, Galvan FH, Carlos JA, et al. A comparison of MSM stigma, HIV stigma and depression in HIV-positive Latino and African American men who have sex with men (MSM). AIDS Behav. 2013;17(4):1454–64.PubMedCrossRefGoogle Scholar
  38. 38.
    Farber EW, Shahane AA, Brown JL, Campos PE. Perceived stigma reductions following participation in mental health services integrated within community-based HIV primary care. AIDS Care. 2014;26(6):750–3.PubMedCrossRefGoogle Scholar
  39. 39.
    Simoni JM, Wiebe JS, Sauceda JA, et al. A preliminary RCT of CBT-AD for adherence and depression among HIV-positive Latinos on the U.S.-Mexico border: the Nuevo Dia study. AIDS Behav. 2013;17(8):2816–29.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Safren SA, O’Cleirigh C, Tan JY, et al. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. Health Psychol. 2009;28(1):1–10.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Safren SA, O’Cleirigh CM, Bullis JR, Otto MW, Stein MD, Pollack MH. Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected injection drug users: a randomized controlled trial. J Consult Clin Psychol. 2012;80(3):404–15.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Newcomb ME, Bedoya CA, Blashill AJ, et al. Description and demonstration of cognitive behavioral therapy to enhance antiretroviral therapy adherence and treat depression in HIV-infected adults. Cogn Behav Pract. (in press) 2014.Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Luke D. Mitzel
    • 1
    Email author
  • Peter A. Vanable
    • 1
    Email author
  • Jennifer L. Brown
    • 2
  • Rebecca A. Bostwick
    • 3
  • Shannon M. Sweeney
    • 1
  • Michael P. Carey
    • 4
  1. 1.Department of PsychologySyracuse UniversitySyracuseUSA
  2. 2.Department of Psychological SciencesTexas Tech UniversityLubbockUSA
  3. 3.Lerner Center for Public Health PromotionSyracuse UniversitySyracuseUSA
  4. 4.Centers for Behavioral and Preventive MedicineThe Miriam Hospital and Brown UniversityProvidenceUSA

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