Advertisement

Pathways to Health: an Examination of HIV-Related Stigma, Life Stressors, Depression, and Substance Use

  • Tiffany R. Glynn
  • Maria M. Llabre
  • Jasper S. Lee
  • C. Andres Bedoya
  • Megan M. Pinkston
  • Conall O’Cleirigh
  • Steven A. SafrenEmail author
Article

Abstract

Background

Despite antiretroviral treatment (ART) being an efficacious treatment for HIV, essentially making it a chronic non-terminal illness, two related and frequent concerns for many people living with HIV/AIDS (PLWHA) continue to be HIV-related stigma and life stress. These two variables are frequently associated with depression, substance use, and poorer functional health. Studies to date have not fully examined the degree to which these constructs may be associated within one model, which could reveal a more nuanced understanding of how HIV-related stigma and life stress affect functional health in PLWHA.

Methods

The current study employed hybrid structural equation modeling to examine the interconnectedness and potential indirect relationships of HIV-related stigma and life stress to worse health through substance use and depression, controlling for ART adherence and age. Participants were 240 HIV-infected individuals who completed a biopsychosocial assessment battery upon screening for an RCT on treating depression in those infected with HIV.

Results

Both HIV-related stigma and stressful life events were directly related to depression, and depression was directly related to health. There were significant indirect effects from stigma and stress to health via depression. There were no significant effects involving substance use.

Conclusion

It is important to continue to develop ways to address stigma, stressful life events, and their effects on distress in those living with HIV. Expanding our knowledge of disease progression risk factors beyond ART adherence is important to be able to design adjuvant interventions, particularly because treatment means that people living with HIV have markedly improved life expectancy and that successful treatment means that HIV is not transmittable to others.

Keywords

HIV-related stigma Stressful life events HIV Depression Substance use 

Notes

Funding Information

The project described was supported by R01MH084757 (Safren) from the National Institute of Mental Health. Some of the author time was funded by 9K24DA040489 (Safren) from the National Institute on Drug Abuse.

Compliance with Ethical Standards

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, or any of the other funders.

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Samji H, Cescon A, Hogg RS, Modur SP, Althoff KN, Buchacz K, et al. Closing the gap: increases in life expectancy among treated HIV-positive individuals in the United States and Canada. PLoS One. 2013;8(12):e81355.  https://doi.org/10.1371/journal.pone.0081355.Google Scholar
  2. 2.
    Teeraananchai S, Kerr S, Amin J, Ruxrungtham K, Law M. Life expectancy of HIV-positive people after starting combination antiretroviral therapy: a meta-analysis. HIV Med. 2017;18(4):256–66.Google Scholar
  3. 3.
    Goodenow MM. Director’s update: why is U=U a game changer?: Office of AIDS Research National Institutes of Health; 2018.Google Scholar
  4. 4.
    Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Antiretroviral therapy for the prevention of HIV-1 transmission. N Engl J Med. 2016;375(9):830–9.Google Scholar
  5. 5.
    Bavinton BR, Pinto AN, Phanuphak N, Grinsztejn B, Prestage GP, Zablotska-Manos IB, et al. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV. 2018;5(8):e438–47.  https://doi.org/10.1016/s2352-3018(18)30132-2.Google Scholar
  6. 6.
    Rodger A, Cambiano V, Bruun T, et al. Risk of HIV transmission through condomless sex in MSM couples with suppressive ART: the PARTNER2 study extended results in gay men. 22nd International AIDS Conference; July 23-27; Amsterdam, Netherlands; 2018.Google Scholar
  7. 7.
    Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316(2):171–81.  https://doi.org/10.1001/jama.2016.5148.Google Scholar
  8. 8.
    Turan B, Hatcher AM, Weiser SD, Johnson MO, Rice WS, Turan JM. Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. Am J Public Health. 2017;107(6):863–9.Google Scholar
  9. 9.
    Health Resources and Services Administration (HRSA). Executive summary: trauma and HIV. Rockville, MD: HIV/AIDS Bureau Division of Policy and Data Consultation Overview; 2015.Google Scholar
  10. 10.
    Nightingale VR, Sher TG, Mattson M, Thilges S, Hansen NBJA. Behavior. The effects of traumatic stressors and HIV-related trauma symptoms on health and health related quality of life. AIDS Behav. 2011;15(8):1870–8.  https://doi.org/10.1007/s10461-011-9980-4.Google Scholar
  11. 11.
    Logie C, Gadalla T. Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care. 2009;21(6):742–53.Google Scholar
  12. 12.
    Rueda S, Mitra S, Chen S, Gogolishvili D, Globerman J, Chambers L, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses. BMJ Open. 2016;6(7):e011453.Google Scholar
  13. 13.
    Wolitski RJ, Pals SL, Kidder DP, Courtenay-Quirk C, Holtgrave DR. The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV. AIDS Behav. 2009;13(6):1222–32.Google Scholar
  14. 14.
    Link BG, Phelan JC. Stigma and its public health implications. Lancet. 2006;367(9509):528–9.Google Scholar
  15. 15.
    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.Google Scholar
  16. 16.
    Hatzenbuehler ML, Nolen-Hoeksema S, Dovidio J. How does stigma “get under the skin”? The mediating role of emotion regulation. Psychol Sci. 2009;20(10):1282–9.Google Scholar
  17. 17.
    Charles B, Jeyaseelan L, Pandian AK, Sam AE, Thenmozhi M, Jayaseelan V. Association between stigma, depression and quality of life of people living with HIV/AIDS (PLHA) in South India–a community based cross sectional study. BMC Public Health. 2012;12(1):463.Google Scholar
  18. 18.
    Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6(4):309–19.Google Scholar
  19. 19.
    Levi-Minzi MA, Surratt HL. HIV stigma among substance abusing people living with HIV/AIDS: implications for HIV treatment. AIDS Patient Care STDs. 2014;28(8):442–51.Google Scholar
  20. 20.
    Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011;58(2):181–7.Google Scholar
  21. 21.
    Edelman EJ, Cole CA, Richardson W, Boshnack N, Jenkins H, Rosenthal MS. Stigma, substance use and sexual risk behaviors among HIV-infected men who have sex with men: a qualitative study. Prev Med Rep. 2016;3:296–302.Google Scholar
  22. 22.
    Russell AL, Tasker JG, Lucion AB, Fiedler J, Munhoz CD, Wu TYJ, et al. Factors promoting vulnerability to dysregulated stress reactivity and stress-related disease. J Neuroendocrinol. 2018;30:e12641.  https://doi.org/10.1111/jne.12641.Google Scholar
  23. 23.
    Pearlin LI, Schieman S, Fazio EM, Meersman SC. Stress, health, and the life course: some conceptual perspectives. J Health Soc Behav. 2005;46(2):205–19.  https://doi.org/10.1177/002214650504600206.Google Scholar
  24. 24.
    Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539–45.Google Scholar
  25. 25.
    Mugavero MJ, Raper JL, Reif S, Whetten K, Leserman J, Thielman NM, et al. Overload: the impact of incident stressful events on antiretroviral medication adherence and virologic failure in a longitudinal, multi-site HIV cohort study. Psychosom Med. 2009;71(9):920–6.  https://doi.org/10.1097/PSY.0b013e3181bfe8d2.Google Scholar
  26. 26.
    Kołodziej J. Effects of stress on HIV infection progression. HIV AIDS Rev. 2016;15(1):13–6.  https://doi.org/10.1016/j.hivar.2015.07.003.Google Scholar
  27. 27.
    Ironson G, O’Cleirigh C, Kumar M, Kaplan L, Balbin E, Kelsch CB, et al. Psychosocial and neurohormonal predictors of HIV disease progression (CD4 cells and viral load): a 4 year prospective study. J AIDS Behav. 2015;19(8):1388–97.  https://doi.org/10.1007/s10461-014-0877-x.Google Scholar
  28. 28.
    Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298(14):1685–7.Google Scholar
  29. 29.
    Slot M, Sodemann M, Gabel C, Holmskov J, Laursen T, Rodkjaer L. Factors associated with risk of depression and relevant predictors of screening for depression in clinical practice: a cross-sectional study among HIV-infected individuals in Denmark. HIV Med. 2015;16(7):393–402.Google Scholar
  30. 30.
    Sinha R. Chronic stress, drug use, and vulnerability to addiction. Ann N Y Acad Sci. 2008;1141(1):105–30.Google Scholar
  31. 31.
    Koob G, Kreek MJ. Stress, dysregulation of drug reward pathways, and the transition to drug dependence. Am J Psychiatry. 2007;164(8):1149–59.Google Scholar
  32. 32.
    Reif S, Mugavero M, Raper J, Thielman N, Leserman J, Whetten K, et al. Highly stressed: stressful and traumatic experiences among individuals with HIV/AIDS in the Deep South. AIDS Care. 2011;23(2):152–62.  https://doi.org/10.1080/09540121.2010.498872.Google Scholar
  33. 33.
    Rabkin JG. HIV and depression: 2008 review and update. Curr HIV/AIDS Rep. 2008;5(4):163–71.Google Scholar
  34. 34.
    Ironson G, Fitch C, Stuetzle R. Depression and survival in a 17-year longitudinal study of people with HIV: moderating effects of race and education. Psychosom Med. 2017;79(7):749–56.Google Scholar
  35. 35.
    Cook JA, Burke-Miller JK, Cohen MH, Cook RL, Vlahov D, Wilson TE, et al. Crack cocaine, disease progression, and mortality in a multi-center cohort of HIV-1 positive women. AIDS. 2008;22(11):1355–63.Google Scholar
  36. 36.
    Baum MK, Rafie C, Lai S, Sales S, Page B, Campa A. Crack-cocaine use accelerates HIV disease progression in a cohort of HIV-positive drug users. J Acquir Immune Defic Syndr. 2009;50(1):93–9.Google Scholar
  37. 37.
    Carrico AW. Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV. Life Sci. 2011;88(21–22):940–7.Google Scholar
  38. 38.
    López CM, Hahn CK, Gilmore AK, Danielson CK. Tailoring cognitive behavioral therapy for trauma-exposed persons living with HIV. Cogn Behav Pract. 2019.  https://doi.org/10.1016/j.cbpra.2019.02.006.
  39. 39.
    Kessler RC. The epidemiology of dual diagnosis. Biol Psychiatry. 2004;56(10):730–7.  https://doi.org/10.1016/j.biopsych.2004.06.034.Google Scholar
  40. 40.
    Safren SA, Bedoya CA, O’Cleirigh C, et al. Treating depression and adherence (CBT-AD) in patients with HIV in care: A three-arm randomized controlled trial. Lancet. 2016;3(11):e529.Google Scholar
  41. 41.
    Kalichman SC, Amaral CM, Swetzes C, Jones M, Macy R, Kalichman MO, et al. A simple single-item rating scale to measure medication adherence: further evidence for convergent validity. J Int Assoc Physicians AIDS Care. 2009;8(6):367–74.  https://doi.org/10.1177/1545109709352884.Google Scholar
  42. 42.
    Sarason IG, Johnson JH, Siegel JM. Assessing the impact of life changes: development of the life experiences survey. J Consult Clin Psychol. 1978;46(5):932–46.Google Scholar
  43. 43.
    Manuzak JA, Gott TM, Kirkwood JS, Coronado E, Hensley-McBain T, Miller C, et al. Heavy cannabis use associated with reduction in activated and inflammatory immune cell frequencies in antiretroviral therapy–treated human immunodeficiency virus–infected individuals. Clin Infect Dis. 2018;66(12):1872–82.  https://doi.org/10.1093/cid/cix1116.Google Scholar
  44. 44.
    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.Google Scholar
  45. 45.
    Kanter JW, Mulick PS, Busch AM, Berlin KS, Martell CR. The behavioral activation for depression scale (BADS): psychometric properties and factor structure. J Psychopathol Behav Assess. 2007;29(3):191–202.Google Scholar
  46. 46.
    Montgomery SA, Åsberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134(4):382–9.Google Scholar
  47. 47.
    Justice A, Holmes W, Gifford A, et al. Development and validation of a self-completed HIV symptom index. J Clin Epidemiol. 2001;54(12):S77–90.Google Scholar
  48. 48.
    Muthén L, Muthén B. Mplus Version 7. Los Angeles, CA; 1998.Google Scholar
  49. 49.
    UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS; 2014.Google Scholar
  50. 50.
    Kalichman SC. The harms of internalized AIDS stigma: a comment on Tsai et al. Ann Behav Med. 2013;46(3):256–7.Google Scholar
  51. 51.
    Varni SE, Miller CT, McCuin T, Solomon S. Disengagement and engagement coping with HIV/AIDS stigma and psychological well-being of people with HIV/AIDS. J Soc Clin Psychol. 2012;31(2):123–50.Google Scholar
  52. 52.
    Brener L, Callander D, Slavin S, de Wit J. Experiences of HIV stigma: the role of visible symptoms, HIV centrality and community attachment for people living with HIV. AIDS Care. 2013;25(9):1166–73.Google Scholar
  53. 53.
    Earnshaw VA, Lang SM, Lippitt M, Jin H, Chaudoir SR. HIV stigma and physical health symptoms: do social support, adaptive coping, and/or identity centrality act as resilience resources? AIDS Behav. 2015;19(1):41–9.Google Scholar
  54. 54.
    Stangl AL, Lloyd JK, Brady LM, Holland CE, Baral S. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? JIAS. 2013;16(3S2):18734.  https://doi.org/10.7448/IAS.16.3.18734.Google Scholar
  55. 55.
    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.Google Scholar
  56. 56.
    Logie CH, James L, Tharao W, Loutfy MR. HIV, gender, race, sexual orientation, and sex work: a qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med. 2011;8(11):e1001124.Google Scholar
  57. 57.
    Earnshaw VA, Kalichman SC. Stigma experienced by people living with HIV/AIDS. In: Liamputtong P, editor. Stigma, discrimination and living with HIV/AIDS: a cross-cultural perspective. New York: Springer; 2013. p. 23–38.Google Scholar
  58. 58.
    Antoni MH. Stress management effects on psychological, endocrinological, and immune functioning in men with HIV infection: empirical support for a psychoneuroimmunological model. Stress. 2003;6(3):173–88.Google Scholar
  59. 59.
    Moraes LJ, Miranda MB, Loures LF, Mainieri AG, Mármora CHC. A systematic review of psychoneuroimmunology-based interventions AU - Moraes, Lucam. J Psychol Health Med. 2018;23(6):635–52.  https://doi.org/10.1080/13548506.2017.1417607.Google Scholar
  60. 60.
    Antoni MH, Carrico AW, Durán RE, Spitzer S, Penedo F, Ironson G, et al. Randomized clinical trial of cognitive behavioral stress management on human immunodeficiency virus viral load in gay men treated with highly active antiretroviral therapy. Psychosom Med. 2006;68(1):143–51.Google Scholar
  61. 61.
    Antoni MH, Cruess DG, Klimas N, Maher K, Cruess S, Kumar M, et al. Stress management and immune system reconstitution in symptomatic HIV-infected gay men over time: effects on transitional naive T cells (CD4+CD45RA+CD29+). Am J Psychiatry. 2002;159(1):143–5.  https://doi.org/10.1176/appi.ajp.159.1.143.Google Scholar
  62. 62.
    Remien RH, Exner T, Kertzner RM, Ehrhardt AA, Rotheram-Borus MJ, Johnson MO, et al. Depressive symptomatology among HIV-positive women in the era of HAART: a stress and coping model. Am J Community Psychol. 2006;38(3–4):275–85.Google Scholar
  63. 63.
    Carrico AW, Antoni MH, Weaver KE, Lechner SC, Schneiderman N. Cognitive—behavioural stress management with HIV-positive homosexual men: mechanisms of sustained reductions in depressive symptoms. Chronic Illn. 2005;1(3):207–15.Google Scholar
  64. 64.
    Carrico AW, Antoni MH, Durán RE, Ironson G, Penedo F, Fletcher MA, et al. Reductions in depressed mood and denial coping during cognitive behavioral stress management with HIV-positive gay men treated with HAART. Ann Behav Med. 2006;31(2):155–64.Google Scholar
  65. 65.
    Rodkjaer LO, Laursen T, Seeberg K, Drouin M, Johansen H, Dyrehave C, et al. The effect of a mind–body intervention on mental health and coping self-efficacy in HIV-infected individuals: a feasibility study. J Altern Complement Med. 2017;23(5):326–30.Google Scholar
  66. 66.
    O’Cleirigh C, Ironson G, Smits JAJ. Does distress tolerance moderate the impact of major life events on psychosocial variables and behaviors important in the management of HIV? Behav Ther. 2007;38(3):314–23.  https://doi.org/10.1016/j.beth.2006.11.001.Google Scholar
  67. 67.
    Whetten K, Leserman J, Lowe K, Stangl D, Thielman N, Swartz M, et al. Prevalence of childhood sexual abuse and physical trauma in an HIV-positive sample from the deep south. Am J Public Health. 2006;96(6):1028–30.  https://doi.org/10.2105/ajph.2005.063263.Google Scholar
  68. 68.
    Wong MD, Sarkisian CA, Davis C, Kinsler J, Cunningham WE. The association between life chaos, health care use, and health status among HIV-infected persons. J Gen Intern Med. 2007;22(9):1286–91.  https://doi.org/10.1007/s11606-007-0265-6.Google Scholar
  69. 69.
    Sales JM, Swartzendruber A, Phillips AL. Trauma-informed HIV prevention and treatment. Curr HIV/AIDS Rep. 2016;13(6):374–82.  https://doi.org/10.1007/s11904-016-0337-5.Google Scholar
  70. 70.
    Sin NL, DiMatteo MR. Depression treatment enhances adherence to antiretroviral therapy: a meta-analysis. Ann Behav Med. 2014;47(3):259–69.  https://doi.org/10.1007/s12160-013-9559-6.Google Scholar
  71. 71.
    Dale SK, Safren SA. Striving towards empowerment and medication adherence (STEP-AD): a tailored cognitive behavioral treatment approach for black women living with HIV. Cogn Behav Pract. 2018;25(3):361–76.  https://doi.org/10.1016/j.cbpra.2017.10.004.Google Scholar
  72. 72.
    Sikkema KJ, Mulawa MI, Robertson C, Watt MH, Ciya N, Stein DJ, et al. Improving AIDS care after trauma (ImpACT): pilot outcomes of a coping intervention among HIV-infected women with sexual trauma in South Africa. AIDS Behav. 2018;22(3):1039–52.  https://doi.org/10.1007/s10461-017-2013-1.Google Scholar
  73. 73.
    Crockett KB, Kalichman SC, Kalichman MO, Cruess DG, Katner HP. Experiences of HIV-related discrimination and consequences for internalised stigma, depression and alcohol use. Psychol Health. 2019:1–15.  https://doi.org/10.1080/08870446.2019.1572143.
  74. 74.
    Centers for Disease Control and Prevention [CDC]. HIV Among Transgender People. 2018. https://www.cdc.gov/hiv/group/gender/transgender/. Accessed on 3/22/19.
  75. 75.
    Burch LS, Smith CJ, Phillips AN, Johnson MA, Lampe FC. Socioeconomic status and response to antiretroviral therapy in high-income countries: a literature review. AIDS. 2016;30(8):1147–62.  https://doi.org/10.1097/qad.0000000000001068.Google Scholar
  76. 76.
    Sherr L, Clucas C, Harding R, Sibley E, Catalan J. HIV and depression–a systematic review of interventions. Psychol Health Med. 2011;16(5):493–527.Google Scholar

Copyright information

© International Society of Behavioral Medicine 2019

Authors and Affiliations

  1. 1.Department of PsychologyUniversity of MiamiCoral GablesUSA
  2. 2.Department of Psychiatry, The Fenway InstituteMassachusetts General Hospital/Harvard Medical SchoolBostonUSA
  3. 3.Department of Psychiatry and Human Behavior, The Miriam Hospital, Clinical Behavioral Medicine Service of the Immunology CenterWarren Alpert Medical School of Brown UniversityProvidenceUSA

Personalised recommendations