Annals of Behavioral Medicine

, Volume 48, Issue 1, pp 26–37 | Cite as

The Dynamic Relationship Between Social Support and HIV-Related Stigma in Rural Uganda

  • Sae Takada
  • Sheri D. Weiser
  • Elias Kumbakumba
  • Conrad Muzoora
  • Jeffrey N. Martin
  • Peter W. Hunt
  • Jessica E. Haberer
  • Annet Kawuma
  • David R. Bangsberg
  • Alexander C. Tsai
Original Article

Abstract

Background

Cross-sectional studies show that human immunodeficiency virus (HIV) stigma is negatively correlated with social support.

Purpose

The purpose of this study is to examine the bidirectional relationship between social support and HIV stigma.

Methods

We collected quarterly data from a cohort of 422 people living with HIV in Uganda, followed for a median of 2.1 years. We used multilevel regression to model the contemporaneous and 3-month-lagged associations between social support and both enacted and internalized stigma.

Results

Lagged enacted stigma was negatively correlated with emotional and instrumental social support, and lagged instrumental social support was negatively correlated with enacted stigma. Internalized stigma and emotional social support had reciprocal lagged associations.

Conclusions

Interventions to reduce enacted stigma may strengthen social support for people living with HIV. Improved social support may in turn have a protective influence against future enacted and internalized stigma.

Keywords

HIV/AIDS Stigma Social support Uganda 

Supplementary material

12160_2013_9576_MOESM1_ESM.docx (79 kb)
ESM 1(DOCX 78 kb)

References

  1. 1.
    Goffman E. Stigma; notes on the management of spoiled identity. Englewood Cliffs: Prentice-Hall; 1963.Google Scholar
  2. 2.
    Fortenberry JD, McFarlane M, Bleakley A, et al. Relationships of stigma and shame to gonorrhea and HIV screening. Am J Public Health. 2002; 92: 378-381.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Wolfe WR, Weiser SD, Bangsberg DR, et al. Effects of HIV-related stigma among an early sample of patients receiving antiretroviral therapy in Botswana. AIDS Care. 2006; 18: 931-933.PubMedCrossRefGoogle Scholar
  4. 4.
    Pitpitan EV, Kalichman SC, Eaton LA, et al. AIDS-related stigma, HIV testing, and transmission risk among patrons of informal drinking places in Cape Town. South Africa. Ann Behav Med. 2012; 43: 362-371.PubMedCentralPubMedCrossRefGoogle Scholar
  5. 5.
    Rintamaki LS, Davis TC, Skripkauskas S, Bennett CL, Wolf MS. Social stigma concerns and HIV medication adherence. AIDS Pat Care STDs. 2006; 20: 359-368.CrossRefGoogle Scholar
  6. 6.
    Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser SD, Bangsberg DR, Tsai AC. Impact of HIV-related stigma on HIV treatment adherence: Systematic review, meta-synthesis, and conceptual model. J Int AIDS Soc. 2013;16:18640.Google Scholar
  7. 7.
    Siedner MJ, Tsai AC, Muzoora C, et al. Treatment as long-term prevention: Sustained reduction in HIV sexual transmission risk with use of antiretroviral therapy in rural Uganda. AIDS. 2013, in press.Google Scholar
  8. 8.
    Schuster MA, Collins R, Cunningham WE, et al. Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care. J Gen Intern Med. 2005; 20: 807-813.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Bogart LM, Cowgill BO, Kennedy D, et al. HIV-related stigma among people with HIV and their families: A qualitative analysis. AIDS Behav. 2008; 12: 244-254.PubMedCrossRefGoogle Scholar
  10. 10.
    Tsai AC, Bangsberg DR, Frongillo EA, et al. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Soc Sci Med. 2012; 74: 2012-2019.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Steward WT, Herek GM, Ramakrishna J, et al. HIV-related stigma: Adapting a theoretical framework for use in India. Soc Sci Med. 2008; 67: 1225-1235.PubMedCentralPubMedCrossRefGoogle Scholar
  12. 12.
    Simbayi LC, Kalichman S, Strebel A, et al. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007; 64: 1823-1831.PubMedCrossRefGoogle Scholar
  13. 13.
    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: 1266-1275.PubMedCrossRefGoogle Scholar
  14. 14.
    Galvan FH, Davis EM, Banks D, Bing EG. HIV stigma and social support among African Americans. AIDS Pat Care STDs. 2008; 22: 423-436.CrossRefGoogle Scholar
  15. 15.
    Mak WW, Cheung RY, Law RW, et al. Examining attribution model of self-stigma on social support and psychological well-being among people with HIV+/AIDS. Soc Sci Med. 2007; 64: 1549-1559.PubMedCrossRefGoogle Scholar
  16. 16.
    Cohen S, McKay G. Social support, stress, and the buffering hypothesis: A theoretical analysis. In: Baum A, Singer JE, Taylor SE, eds. Handbook of Psychology and Health. Hillsdale: Erlbaum, 1984: 253-267.Google Scholar
  17. 17.
    Friedland J, Renwick R, McColl M. Coping and social support as determinants of quality of life in HIV/AIDS. AIDS Care. 1996; 8: 15-32.PubMedCrossRefGoogle Scholar
  18. 18.
    Leserman J, Jackson ED, Petitto JM, et al. Progression to AIDS: The effects of stress, depressive symptoms, and social support. Psychosom Med. 1999; 61: 397-406.PubMedCrossRefGoogle Scholar
  19. 19.
    Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. 2000; 51: 843-857.PubMedCrossRefGoogle Scholar
  20. 20.
    Umberson D, Crosnoe R, Reczek C. Social relationships and health behavior across life course. Annu Rev Sociol. 2010; 36: 139-157.PubMedCentralPubMedCrossRefGoogle Scholar
  21. 21.
    Berkman LF, Syme SL. Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. Am J Epidemiol. 1979; 109: 186-204.PubMedGoogle Scholar
  22. 22.
    Cohen S. Social relationships and health. Am Psychol. 2004; 59: 676-684.PubMedCrossRefGoogle Scholar
  23. 23.
    Uchino BN. Social support and health: A review of physiological processes potentially underlying links to disease outcomes. J Behav Med. 2006; 29: 377-387.PubMedCrossRefGoogle Scholar
  24. 24.
    Taylor SE, Repetti RL, Seeman T. Health psychology: What is an unhealthy environment and how does it get under the skin? Annu Rev Psychol. 1997; 48: 411-447.PubMedCrossRefGoogle Scholar
  25. 25.
    Allport GW. The Nature of Prejudice: Reading: Addison-Wesley; 1979.Google Scholar
  26. 26.
    Corrigan PW, Watson AC. The paradox of self-stigma and mental illness. Clin Psychol-Sci Pr. 2002; 9: 35-53.CrossRefGoogle Scholar
  27. 27.
    Pachankis JE. The psychological implications of concealing a stigma: A cognitive-affective-behavioral model. Psychol Bull. 2007; 133: 328-345.PubMedCrossRefGoogle Scholar
  28. 28.
    Scheff TJ. Being mentally ill: A sociological theory. Chicago: Aldine, 1966.Google Scholar
  29. 29.
    Link BG, Cullen FT, Struening E, Shrout PE, Dohrenwent BP. A modified labeling theory approach to mental disorders: An empirical assessment. Am Sociol Rev. 1989; 54: 400-423.CrossRefGoogle Scholar
  30. 30.
    Link BG. Understanding labeling effects in the area of mental disorders: An assessment of the effects of expectations of rejection. Am Sociol Rev. 1987; 52: 96-112.CrossRefGoogle Scholar
  31. 31.
    Carels RA, Young KM, Wott CB, et al. Internalized weight stigma and its ideological correlates among weight loss treatment seeking adults. Eat Weight Disord. 2009; 14: e92-97.PubMedCentralPubMedCrossRefGoogle Scholar
  32. 32.
    Livingston JD, Boyd JE. Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Soc Sci Med. 2010; 71: 2150-2161.PubMedCrossRefGoogle Scholar
  33. 33.
    Yang LH, Kleinman A, Link BG, et al. Culture and stigma: Adding moral experience to stigma theory. Soc Sci Med. 2007; 64: 1524-1535.PubMedCrossRefGoogle Scholar
  34. 34.
    Yang LH, Kleinman A. ‘Face’ and the embodiment of stigma in China: The cases of schizophrenia and AIDS. Soc Sci Med. 2008; 67: 398-408.PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Chandra PS, Deepthivarma S, Manjula V. Disclosure of HIV infection in south India: Patterns, reasons and reactions. AIDS Care. 2003; 15: 207-215.PubMedCrossRefGoogle Scholar
  36. 36.
    Hays RB, McKusick L, Pollack L, et al. Disclosing HIV seropositivity to significant others. AIDS. 1993; 7: 425-431.PubMedCrossRefGoogle Scholar
  37. 37.
    Tsai AC, Bangsberg DR, Kegeles SM, et al. Internalized stigma, social distance, and disclosure of HIV seropositivity in rural Uganda. Ann Behav Med. 2013;46:285–294.Google Scholar
  38. 38.
    Mayanja BN, Ekoru K, Namugenyi H, Lubega R, Mugisha JO. Patients’ worries before starting antiretroviral therapy and their association with treatment adherence and outcomes: A prospective study in rural Uganda, 2004–2009. BMC Res Notes. 2013; 6: 187.PubMedCentralPubMedCrossRefGoogle Scholar
  39. 39.
    Tsai AC, Bangsberg DR, Emenyonu N, et al. The social context of food insecurity among persons living with HIV/AIDS in rural Uganda. Soc Sci Med. 2011; 73: 1717-1724.PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Weiser SD, Tuller DM, Frongillo EA, et al. Food insecurity as a barrier to sustained antiretroviral therapy adherence in Uganda. PLoS One. 2010; 5: e10340.PubMedCentralPubMedCrossRefGoogle Scholar
  41. 41.
    Geng EH, Bwana MB, Kabakyenga J, et al. Diminishing availability of publicly funded slots for antiretroviral initiation among HIV-infected ART-eligible patients in Uganda. PLoS One. 2010; 5: e14098.PubMedCentralPubMedCrossRefGoogle Scholar
  42. 42.
    Siedner MJ, Lankowski A, Tsai AC, et al. GPS-measured distance to clinic, but not self-reported transportation factors, are associated with missed HIV clinic visits in rural Uganda. AIDS. 2013;27:1503–1508.Google Scholar
  43. 43.
    Antelman G, Smith Fawzi MC, Kaaya S, et al. Predictors of HIV-1 serostatus disclosure: A prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania. AIDS. 2001; 15: 1865-1874.PubMedCrossRefGoogle Scholar
  44. 44.
    Broadhead WE, Gehlbach SH, de Gruy FV, Kaplan BH. The Duke-UNC functional social support questionnaire. Measurement of social support in family medicine patients. Med Care. 1988; 26: 709-723.PubMedCrossRefGoogle Scholar
  45. 45.
    Kalichman SC, Simbayi LC, Cloete A, et al. Measuring AIDS stigmas in people living with HIV/AIDS: The internalized AIDS-related stigma scale. AIDS Care. 2009; 21: 87-93.PubMedCrossRefGoogle Scholar
  46. 46.
    Kalichman SC, Simbayi LC, Jooste S, et al. Development of a brief scale to measure AIDS-related stigma in South Africa. AIDS Behav. 2005; 9: 135-143.PubMedCrossRefGoogle Scholar
  47. 47.
    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.PubMedCentralPubMedCrossRefGoogle Scholar
  48. 48.
    Nyblade L, & MacQuarrie, K. Can we measure HIV/AIDS-related stigma and discrimination? Current knowledge about quantifying stigma in developing countries. Washington: US Agency for International Development; 2006.Google Scholar
  49. 49.
    Wu AW, Revicki DA, Jacobson D, Malitz FE. Evidence for reliability, validity and usefulness of the medical outcomes study HIV health survey (MOS-HIV). Qual Life Res. 1997; 6: 481-493.PubMedCrossRefGoogle Scholar
  50. 50.
    Wu AW, Rubin HR, Mathews WC, et al. A health status questionnaire using 30 items from the Medical Outcomes Study, Preliminary validation in persons with early HIV infection. Med Care. 1991; 29: 786-798.PubMedCrossRefGoogle Scholar
  51. 51.
    Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behav Sci. 1974; 19: 1-15.PubMedCrossRefGoogle Scholar
  52. 52.
    Bolton P, & Ndogoni L. Cross-cultural assessment of trauma-related mental illness (phase II): A report of research conducted by World Vision Uganda and The Johns Hopkins University; 2001.Google Scholar
  53. 53.
    Kalichman SC, Sikkema KJ, Somlai A. Assessing persons with human immunodeficiency virus (HIV) infection using the Beck Depression Inventory: Disease processes and other potential confounds. J Pers Assess. 1995; 64: 86-100.PubMedCrossRefGoogle Scholar
  54. 54.
    Kalichman SC, Rompa D, Cage M. Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV-AIDS. J Nerv Ment Dis. 2000; 188: 662-670.PubMedCrossRefGoogle Scholar
  55. 55.
    Winokur A, Winokur DF, Rickels K, Cox DS. Symptoms of emotional distress in a family planning service: stability over a four-week period. Brit J Psych. 1984; 144: 395-399.Google Scholar
  56. 56.
    Filmer D, Pritchett LH. Estimating wealth effects without expenditure data—or tears: An application to educational enrollments in states of India. Demography. 2001; 38: 115-132.PubMedGoogle Scholar
  57. 57.
    Singer JD, Willett JB. Applied longitudinal data analysis: Modeling change and event occurrence. Oxford: Oxford University Press; 2003.CrossRefGoogle Scholar
  58. 58.
    Prachakul W, Grant JS. Informal caregivers of persons with HIV/AIDS: A review and analysis. J Assoc Nurses AIDS Care. 2003; 14: 55-71.PubMedCrossRefGoogle Scholar
  59. 59.
    Ware NC, Idoko J, Kaaya S, et al. Explaining adherence success in sub-Saharan Africa: An ethnographic study. PLoS Med. 2009; 6: e11.PubMedCrossRefGoogle Scholar
  60. 60.
    McDowell TL, Serovich JM. The effect of perceived and actual social support on the mental health of HIV-positive persons. AIDS Care. 2007; 19: 1223-1229.PubMedCentralPubMedCrossRefGoogle Scholar
  61. 61.
    Weiser S, Wolfe W, Bangsberg D, et al. Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. J Acquir Immune Defic Syndr. 2003; 34: 281-288.PubMedCrossRefGoogle Scholar
  62. 62.
    Wolfe WR, Weiser SD, Leiter K, et al. The impact of universal access to antiretroviral therapy on HIV stigma in Botswana. Am J Public Health. 2008; 98: 1865-1871.PubMedCentralPubMedCrossRefGoogle Scholar
  63. 63.
    Tsai AC, Bangsberg DR, Bwana M, et al. How does antiretroviral treatment attenuate the stigma of HIV? Evidence from a cohort study in rural Uganda. AIDS Behav. 2013; 17: 2725-2731.Google Scholar
  64. 64.
    Farmer P, Leandre F, Mukherjee JS, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet. 2001; 358: 404-409.PubMedCrossRefGoogle Scholar
  65. 65.
    Seeman TE, Bruce ML, McAvay GJ. Social network characteristics and onset of ADL disability: MacArthur studies of successful aging. J Gerontol B Psychol Sci Soc Sci. 1996; 51: S191-200.PubMedCrossRefGoogle Scholar
  66. 66.
    Kaplan RM, Hartwell SL. Differential effects of social support and social network on physiological and social outcomes in men and women with type II diabetes mellitus. J Health Psychol. 1987; 6: 387-398.CrossRefGoogle Scholar

Copyright information

© The Society of Behavioral Medicine 2013

Authors and Affiliations

  • Sae Takada
    • 1
  • Sheri D. Weiser
    • 2
  • Elias Kumbakumba
    • 3
  • Conrad Muzoora
    • 3
  • Jeffrey N. Martin
    • 4
  • Peter W. Hunt
    • 2
  • Jessica E. Haberer
    • 1
    • 5
  • Annet Kawuma
    • 3
  • David R. Bangsberg
    • 1
    • 3
    • 5
  • Alexander C. Tsai
    • 1
    • 5
    • 6
  1. 1.Harvard Medical SchoolBostonUSA
  2. 2.Division of HIV/AIDS and Positive Health ProgramUniversity of California at San FranciscoSan FranciscoUSA
  3. 3.Mbarara University of Science and TechnologyMbararaUganda
  4. 4.Department of Epidemiology and BiostatisticsUniversity of California at San FranciscoSan FranciscoUSA
  5. 5.Center for Global HealthMassachusetts General HospitalBostonUSA
  6. 6.Chester M. Pierce MD Division of Global PsychiatryMassachusetts General HospitalBostonUSA

Personalised recommendations