AIDS and Behavior

, Volume 21, Issue 12, pp 3431–3439 | Cite as

Association between Perceived Discrimination in Healthcare Settings and HIV Medication Adherence: Mediating Psychosocial Mechanisms

  • Bulent Turan
  • Anna Joy Rogers
  • Whitney S. Rice
  • Ghislaine C. Atkins
  • Mardge H. Cohen
  • Tracey E. Wilson
  • Adaora A. Adimora
  • Daniel Merenstein
  • Adebola Adedimeji
  • Eryka L. Wentz
  • Igho Ofotokun
  • Lisa Metsch
  • Phyllis C. Tien
  • Mallory O. Johnson
  • Janet M. Turan
  • Sheri D. Weiser
Original Paper


There is insufficient research on the impact of perceived discrimination in healthcare settings on adherence to antiretroviral therapy (ART), particularly among women living with HIV, and even less is known about psychosocial mechanisms that may mediate this association. Cross-sectional analyses were conducted in a sample of 1356 diverse women living with HIV enrolled in the Women’s Interagency HIV Study (WIHS), a multi-center cohort study. Indirect effects analysis with bootstrapping was used to examine the potential mediating roles of internalized stigma and depressive symptoms in the association between perceived discrimination in healthcare settings and ART adherence. Perceived discrimination in healthcare settings was negatively associated with optimal (95% or better) ART adherence (adjusted odds ratio (AOR) = 0.81, p = 0.02, 95% confidence interval (CI) [0.68, 0.97]). Furthermore, internalization of stigma and depressive symptoms mediated the perceived discrimination-adherence association: Serial mediation analyses revealed a significant indirect effect of perceived discrimination in healthcare settings on ART adherence, first through internalized HIV stigma, and then through depressive symptoms (B = − 0.08, SE = 0.02, 95% CI [− 0.12, − 0.04]). Perceiving discrimination in healthcare settings may contribute to internalization of HIV-related stigma, which in turn may lead to depressive symptoms, with downstream adverse effects on ART adherence among women. These findings can guide the design of interventions to reduce discrimination in healthcare settings, as well as interventions targeting psychosocial mechanisms that may impact the ability of women living with HIV to adhere to ART regimens.


HIV Adherence Mental health Stigma Discrimination Depression 



We wish to acknowledge the assistance of the WIHS program staff and the contributions of the participants who enrolled in this study. This study was funded by Women’s Interagency HIV Study (WIHS) sub-study grants from the National Institute of Mental Health, R01MH095683 and R01MH104114. 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). WIHS (Principal Investigators): UAB-MS WIHS (Michael Saag, Mirjam-Colette Kempf, and Deborah Konkle-Parker), U01-AI-103401; Atlanta WIHS (Ighovwerha Ofotokun and Gina Wingood), U01-AI-103408; Bronx WIHS (Kathryn Anastos), U01-AI-035004; Brooklyn WIHS (Howard Minkoff and Deborah Gustafson), U01-AI-031834; Chicago WIHS (Mardge Cohen, Audrey French), U01-AI-034993; Metropolitan Washington WIHS (Mary Young), U01-AI-034994; Miami WIHS (Margaret Fischl and Lisa Metsch), U01-AI-103397; UNC WIHS (Adaora Adimora), U01-AI-103390; Connie Wofsy Women’s HIV Study, Northern California (Ruth Greenblatt, Bradley Aouizerat, and Phyllis Tien), U01-AI-034989; WIHS Data Management and Analysis Center (Stephen Gange and Elizabeth Golub), U01-AI-042590; Southern California WIHS (Alexandra Levine and Marek Nowicki), U01-HD-032632 (WIHS I–WIHS IV). The WIHS is funded primarily by the National Institute of Allergy and Infectious Diseases (NIAID), with additional co-funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA), and the National Institute on Mental Health (NIMH). Targeted supplemental funding for specific projects is also provided by the National Institute of Dental and Craniofacial Research (NIDCR), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Deafness and other Communication Disorders (NIDCD), and the NIH Office of Research on Women’s Health. WIHS data collection is also supported by UL1-TR000004 (UCSF CTSA) and UL1-TR000454 (Atlanta CTSA). This research was also 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. Trainee support was provided by the Agency for Healthcare Research and Quality (Grant No. T32HS013852).


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Copyright information

© Springer Science+Business Media, LLC 2017

Authors and Affiliations

  • Bulent Turan
    • 1
  • Anna Joy Rogers
    • 2
  • Whitney S. Rice
    • 1
  • Ghislaine C. Atkins
    • 1
  • Mardge H. Cohen
    • 3
  • Tracey E. Wilson
    • 4
  • Adaora A. Adimora
    • 5
  • Daniel Merenstein
    • 6
  • Adebola Adedimeji
    • 7
  • Eryka L. Wentz
    • 8
  • Igho Ofotokun
    • 9
  • Lisa Metsch
    • 10
  • Phyllis C. Tien
    • 11
  • Mallory O. Johnson
    • 12
  • Janet M. Turan
    • 2
  • Sheri D. Weiser
    • 13
  1. 1.Department of PsychologyUniversity of Alabama at BirminghamBirminghamUSA
  2. 2.Department of Health Care Organization and Policy, School of Public HealthUniversity of Alabama at BirminghamBirminghamUSA
  3. 3.Department of MedicineStroger HospitalChicagoUSA
  4. 4.Department of Community Health Sciences, School of Public HealthState University of New York Downstate Medical CenterBrooklynUSA
  5. 5.School of Medicine and UNC Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillUSA
  6. 6.Department of Family MedicineGeorgetown University Medical CenterWashingtonUSA
  7. 7.Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxUSA
  8. 8.Department of Epidemiology, Bloomberg School of Public HealthJohns Hopkins UniversityBaltimoreUSA
  9. 9.School of MedicineEmory UniversityAtlantaUSA
  10. 10.Department of Sociomedical SciencesMailman School of Public Health, Columbia UniversityNew YorkUSA
  11. 11.Department of Medicine, Department of Veteran Affairs Medical CenterUniversity of California, San Francisco and Medical ServiceSan FranciscoUSA
  12. 12.Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA
  13. 13.Division of HIV, ID and Global Medicine, Department of MedicineUniversity of California, San FranciscoSan FranciscoUSA

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