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Internalized HIV and Drug Stigmas: Interacting Forces Threatening Health Status and Health Service Utilization Among People with HIV Who Inject Drugs in St. Petersburg, Russia

Abstract

Marked overlap between the HIV and injection drug use epidemics in St. Petersburg, Russia, puts many people in need of health services at risk for stigmatization based on both characteristics simultaneously. The current study examined the independent and interactive effects of internalized HIV and drug stigmas on health status and health service utilization among 383 people with HIV who inject drugs in St. Petersburg. Participants self-reported internalized HIV stigma, internalized drug stigma, health status (subjective rating and symptom count), health service utilization (HIV care and drug treatment), sociodemographic characteristics, and health/behavioral history. For both forms of internalized stigma, greater stigma was correlated with poorer health and lower likelihood of service utilization. HIV and drug stigmas interacted to predict symptom count, HIV care, and drug treatment such that individuals internalizing high levels of both stigmas were at elevated risk for experiencing poor health and less likely to access health services.

Resumen

La frecuente simultaneidad entre el VIH y el consumo de drogas inyectables en San Petersburgo, Rusia, sitúa a muchas personas en la necesidad de disponer de servicios de salud, bajo el riesgo de estigmatización basado en la ocurrencia de ambas características simultáneamente. El presente estudio examinó los efectos independientes y de interacción entre los estigmas internalizados hacia el VIH y hacia las drogas, sobre el estado de salud y la utilización de servicios de salud en 383 personas con VIH que se inyectan drogas en San Petersburgo. Los participantes realizaron autoinformes sobre el estigma internalizado hacia el VIH, el estigma internalizado hacia la droga, el estado de salud (valoración subjetiva y enumeración de síntomas), la utilización de servicios de salud (atención de VIH y tratamiento de drogas), las características sociodemográficas y la historia de salud/conductual. Para ambas formas de estigma internalizado, los niveles altos de estigma se correlacionaron con una salud más pobre y con una menor probabilidad de utilización de servicios. El VIH y el estigma hacia las drogas interactuaron para predecir la enumeración de síntomas, la atención del VIH y el tratamiento de drogas, de manera que los individuos que internalizan altos niveles de ambos estigmas se encontraban en riesgo elevado de experimentar problemas de salud y con menos probabilidades de acceder a servicios de salud.

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Notes

  1. For financial status, we assessed perceived economic strain rather than an objective indicator such as annual income because participants reported diverse living situations and levels of financial independence. Additionally, previous research has suggested that subjective measures of socioeconomic status may predict self-rated health more strongly than objective measures [33].

  2. For reference, we also calculated descriptive health characteristics among HIV-negative people who inject drugs from our larger Russian sample: Subjective health rating (on a 0–100 scale) ranged from 20 to 100 (M = 69.21, SD = 14.33; Mdn = 70.0; n = 365) and symptom count (out of 10 possible symptoms) ranged from 0 to 8 (M = .95, SD = 1.75; Mdn = 0.0; n = 364).

  3. Our study was not designed to replicate the findings of Earnshaw et al. [28], so it did not include the same measure of mental health status [43]. We did, however, perform exploratory linear regression analyses of main and interaction effects of internalized HIV stigma and internalized drug stigma on mental health status using an alternate measure [44]. Adjusting for sociodemographic characteristics and health/behavioral history, main effects of both internalized HIV stigma, b = 0.55, SE = 0.27, p = .045, and internalized drug stigma, b = 0.55, SE = 0.26, p = .032 emerged, linking both stigmas to poorer mental health, but no significant interaction effect was detected when the interaction term was added to the model, b = 0.28, SE = 0.22, p = .218.

References

  1. Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, Strathdee SA, et al. Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet. 2008;372(9651):1733–45.

    PubMed  Article  Google Scholar 

  2. Heimer R, White E. Estimation of the number of injection drug users in St. Petersburg, Russia. Drug Alcohol Depend. 2010;109(1–3):79–83.

    PubMed  PubMed Central  Article  Google Scholar 

  3. Niccolai LM, Verevochkin SV, Toussova OV, White E, Barbour R, Kozlov AP, et al. Estimates of HIV incidence among drug users in St. Petersburg, Russia: continued growth of a rapidly expanding epidemic. Eur J Pub Health. 2011;21(5):613–9.

    Article  Google Scholar 

  4. Niccolai LM, Toussova OV, Verevochkin SV, Barbour R, Heimer R, Kozlov AP. High HIV prevalence, suboptimal HIV testing, and low knowledge of HIV-positive serostatus among injection drug users in St. Petersburg, Russia. AIDS Behav. 2010;14(4):932–41.

    PubMed  PubMed Central  Article  Google Scholar 

  5. Abdala N, Carney JM, Durante AJ, Klimov N, Ostrovski D, Somlai AM, et al. Estimating the prevalence of syringe-borne and sexually transmitted diseases among injection drug users in St. Petersburg, Russia. Int J STD AIDS. 2003;14:697–703.

    PubMed  Article  Google Scholar 

  6. Shaboltas AV, Toussova OV, Hoffman IF, Heimer R, Verevochkin SV, Ryder RW, et al. HIV prevalence, socio-demographic and behavioral correlates and recruitment methods among injection drug users in St. Petersburg, Russia. JAIDS. 2006;41:657–63.

    PubMed  Google Scholar 

  7. Eritsyan K, Heimer R, Barbour R, Odinokova V, White E, Rusakova MM, et al. Individual-level, network-level and city-level factors associated with HIV prevalence among people who inject drugs in eight Russian cities: A cross-sectional study. BMJ Open. 2013;3(6):e002645.

    PubMed  PubMed Central  Article  Google Scholar 

  8. Mills HL, White E, Colijn C, Vickerman P, Heimer R. HIV transmission from drug injectors to partners who do not inject, and beyond: Modelling the potential for a generalized heterosexual epidemic in St. Petersburg, Russia. Drug Alcohol Depend. 2013;133(1):242–7.

    PubMed  PubMed Central  Article  Google Scholar 

  9. Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. Am Psychol. 2013;68(4):225–36.

    PubMed  PubMed Central  Article  Google Scholar 

  10. 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.

    PubMed  CAS  Article  Google Scholar 

  11. 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.

    PubMed  Article  Google Scholar 

  12. Kelly J, Amirkhanian Y, Yakovlev A, Musatov V, Meylakhs A, Kuznetsova A, et al. Stigma reduces and social support increases engagement in medical care among persons with HIV infection in St. Petersburg, Russia. J Int AIDS Soc. 2014;17(4 Suppl 3):19618.

    PubMed  PubMed Central  Google Scholar 

  13. King EJ, Maman S, Bowling JM, Moracco KE, Dudina V. The influence of stigma and discrimination on female sex workers’ access to HIV services in St. Petersburg, Russia. AIDS Behav. 2013;17(8):2597–603.

    PubMed  Article  Google Scholar 

  14. Lang K, Neil J, Wright J, Dell CA, Berenbaum S, El-Aneed A. Qualitative investigation of barriers to accessing care by people who inject drugs in Saskatoon, Canada: perspectives of service providers. Subst Abuse Treat Prev Policy. 2013;8:35.

    PubMed  PubMed Central  Article  Google Scholar 

  15. Simmonds L, Coomber R. Injecting drug users: a stigmatised and stigmatising population. Int J Drug Policy. 2009;20(2):121–30.

    PubMed  Article  Google Scholar 

  16. Lang K, El-Aneed A, Berenbaum S, Dell CA, Wright J, McKay ZT. Qualitative assessment of crisis services among persons using injection drugs in the city of Saskatoon. J Subst Use. 2013;18(1):3–11.

    Article  Google Scholar 

  17. Latkin C, Srikrishnan AK, Yang C, Johnson S, Solomon SS, Kumar S, et al. The relationship between drug use stigma and HIV injection risk behaviors among injection drug users in Chennai, India. Drug Alcohol Depend. 2010;110(3):221–7.

    PubMed  PubMed Central  Article  Google Scholar 

  18. Goffman E. Stigma: Notes on the management of spoiled identity. New York, NY: Simon & Schuster, Inc.; 1963.

    Google Scholar 

  19. Link BG, Phelan JC. Conceptualizing stigma. Ann Rev Sociol. 2001;27:363–85.

    Article  Google Scholar 

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

    PubMed  PubMed Central  Article  Google Scholar 

  21. Balabanova Y, Coker R, Atun RA, Drobniewski F. Stigma and HIV infection in Russia. AIDS Care. 2006;18(7):846–52.

    PubMed  CAS  Article  Google Scholar 

  22. McCrae RR, Costa PT, Martin TA, Oryol VE, Senin IG, O’Cleirigh C. Personality correlates of HIV stigmatization in Russia and the United States. J Res Personal. 2007;41(1):190–6.

    Article  Google Scholar 

  23. Lioznov D, Nikolaenko S, editors. HIV-related stigma among intravenous drug users in St. Petersburg, Russia. 6th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention; Rome, Italy; 2011.

  24. Bobrova N, Rhodes T, Power R, Alcorn R, Neifeld E, Krasiukov N, et al. Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities. Drug Alcohol Depend. 2006;82(Suppl 1):S57–63.

    PubMed  Article  Google Scholar 

  25. Rhodes T, Platt L, Sarang A, Vlasov A, Mikhailova L, Monaghan G. Street policing, injecting drug use and harm reduction in a Russian city: a qualitative study of police perspectives. J Urban Health. 2006;83(5):911–25.

    PubMed  PubMed Central  Article  Google Scholar 

  26. Tkatchenko-Schmidt E, Renton A, Gevorgyan R, Davydenko L, Atun R. Prevention of HIV/AIDS among injecting drug users in Russia: opportunities and barriers to scaling-up of harm reduction programmes. Health Policy. 2008;85(2):162–71.

    PubMed  Article  Google Scholar 

  27. Burke SE, Calabrese SK, Dovidio JF, Levina OS, Uusküla A, Niccolai LM, et al. A tale of two cities: stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Järve, Estonia. Soc Sci Med. 2015;130:154–61.

    PubMed  Article  Google Scholar 

  28. Earnshaw VA, Smith LR, Cunningham CO, Copenhaver MM. Intersectionality of internalized HIV stigma and internalized substance use stigma: implications for depressive symptoms. J Health Psychol. 2013. doi:10.1177/1359105313507964.

  29. Li X, Wang H, He G, Fennie K, Williams AB. Shadow on my heart: a culturally grounded concept of HIV stigma among chinese injection drug users. J Assoc Nurses AIDS Care. 2012;23(1):52–62.

    PubMed  PubMed Central  Article  Google Scholar 

  30. Cole ER. Intersectionality and research in psychology. Am Psychol. 2009;64(3):170–80.

    PubMed  Article  Google Scholar 

  31. Cepeda JA, Niccolai LM, Lyubmova A, Kershaw T, Levina OS, Heimer R. High-risk behaviors after icarceration among people who inject drugs in St. Petersburg, Russia. Drug Alcohol Depend. 2014;147:196–202.

    PubMed  Article  Google Scholar 

  32. Cepeda JA, Vetrova MV, Liubimova AI, Levina OS, Heimer R, Niccolai LM. Community reentry challenges after release from prison among people who inject drugs in St. Petersburg, Russia. Int J Prison Health. (in press).

  33. Singh-Manoux A, Marmot MG, Adler NE. Does subjective social status predict health and change in health status better than objective status? Psychosom Med. 2005;67(6):855–61.

    PubMed  Article  Google Scholar 

  34. Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care. 2009;21(1):87–93.

    PubMed  Article  Google Scholar 

  35. Brooks RA. EuroQol: the current state of play. Health Policy (Amsterdam, Netherlands). 1996;37(1):53–72.

    CAS  Article  Google Scholar 

  36. The EuroQol Group. EuroQol-a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199–208.

    Article  Google Scholar 

  37. Mathews WC, May S. EuroQol (EQ-5D) measure of quality of life predicts mortality, emergency department utilization, and hospital discharge rates in HIV-infected adults under care. Health Qual life Outcomes. 2007;5:5.

    PubMed  PubMed Central  Article  Google Scholar 

  38. Nglazi MD, West SJ, Dave JA, Levitt NS, Lambert EV. Quality of life in individuals living with HIV/AIDS attending a public sector antiretroviral service in Cape Town, South Africa. BMC Public Health. 2014;14:676.

    PubMed  PubMed Central  Article  Google Scholar 

  39. Woodhall S, Eriksson T, Nykanen AM, Huhtala H, Rissanen P, Apter D, et al. Impact of HPV vaccination on young women’s quality of life—a five year follow-up study. Eur J Contracept Reprod Health Care. 2011;16(1):3–8.

    PubMed  Article  Google Scholar 

  40. Karnite A, Uusküla A, Luizov A, Rusev A, Talu A, Upite E, et al. Assessment on HIV and TB knowledge and the barriers related to access to care among vulnerable groups: Report on a cross-sectional study among injecting drug users. Estonia: 2014.

  41. Bhandari A, Wagner T. Self-reported utilization of health care services: improving measurement and accuracy. Med Care Res Rev. 2006;63(2):217–35.

    PubMed  Article  Google Scholar 

  42. Aiken LS, West SG. Multiple Regression: Testing and Interpreting Interactions. Thousand Oaks: Sage Publications; 1991.

    Google Scholar 

  43. Irwin M, Artin KH, Oxman MN. Screening for depression in the older adult: criterion validity of the 10-item Center for Epidemiological Studies Depression Scale (CES-D). Arch Intern Med. 1999;159(15):1701–4.

    PubMed  CAS  Article  Google Scholar 

  44. Berwick DM, Murphy JM, Goldman PA, Ware JE Jr, Barsky AJ, Weinstein MC. Performance of a five-item mental health screening test. Med Care. 1991;29(2):169–76.

    PubMed  CAS  Article  Google Scholar 

  45. Burki T. Russia’s drug policy fuels infectious disease epidemics. Lancet Infect Dis. 2012;12(4):275–6.

    PubMed  Article  Google Scholar 

  46. Sullivan LE, Metzger DS, Fudala PJ, Fiellin D. Decreasing international HIV transmission: the role of expanding access to opioid agonist therapies for injection drug users. Addiction. 2005;100:150–8.

    PubMed  Article  Google Scholar 

  47. U.S. Office of National AIDS Policy. National HIV/AIDS strategy for the United States. 2010. Available at: https://www.whitehouse.gov/sites/default/files/uploads/NHAS.pdf. Accessed 23 May 2015.

  48. Baral SD, Poteat T, Strömdahl S, Wirtz AL, Guadamuz TE, Beyrer C. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis. 2013;13(3):214–22.

    PubMed  Article  Google Scholar 

  49. UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2013. 2013.

  50. Earnshaw VA, Quinn DM. The impact of stigma in healthcare on people living with chronic illnesses. J Health Psychol. 2012;17(2):157–68.

    PubMed  Article  Google Scholar 

  51. 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.

    PubMed  PubMed Central  Article  Google Scholar 

  52. Ghavami N, Peplau LA. An intersectional analysis of gender and ethnic stereotypes: testing three hypotheses. Psychol Women Q. 2013;37(1):113–27.

    Article  Google Scholar 

  53. Stephens DP, Phillips LD. Freaks, gold diggers, divas, and dykes: the sociohistorical development of adolescent African American women’s sexual scripts. Sex Cult. 2003;7:3–49.

    Article  Google Scholar 

  54. Buchanan NT, Ormerod AJ. Racialized sexual harassment in the lives of African American women. Women Therapy. 2002;25(3–4):107–24.

    Article  Google Scholar 

  55. Carr ER, Szymanski DM, Taha F, West LM, Kaslow NJ. Understanding the link between multiple oppressions and depression among African American women. Psychol Women Q. 2014;38(2):233–45.

    Article  Google Scholar 

  56. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97.

    PubMed  PubMed Central  Article  Google Scholar 

  57. Quinn DM, Williams MK, Quintana F, Gaskins JL, Overstreet NM, Pishori A, et al. Examining effects of anticipated stigma, centrality, salience, internalization, and outness on psychological distress for people with concealable stigmatized identities. PLoS One. 2014;9(5):e96977.

    PubMed  PubMed Central  Article  Google Scholar 

  58. Sellers RM, Caldwell CH, Schmeelk-Cone KH, Zimmerman MA. Racial identity, racial discrimination, perceived stress, and psychological distress among African American young adults. J Health Soc Behav. 2003;44(3):302–17.

    PubMed  Article  Google Scholar 

  59. Burrow AL, Ong AD. Racial identity as a moderator of daily exposure and reactivity to racial discrimination. Self Identity. 2010;9(4):383–402.

    Article  Google Scholar 

  60. Quinn DM, Earnshaw VA. Understanding concealable stigmatized identities: the role of identity in psychological, physical, and behavioral outcomes. Soc Issues Policy Rev. 2011;5(1):160–90.

    Article  Google Scholar 

  61. Luoma JB, Kohlenberg BS, Hayes SC, Bunting K, Rye AK. Reducing self-stigma in substance abuse through acceptance and commitment therapy: model, manual development, and pilot outcomes. Addict Res Theory. 2008;16(2):149–65.

    Article  Google Scholar 

  62. Hayes SC, Wilson KG, Gifford EV, Bissett R, Piasecki M, Batten SV, et al. A preliminary trial of twelve-step facilitation and acceptance and commitment therapy with polysubstance-abusing methadone-maintained opiate addicts. Behav Therapy. 2004;35:667–88.

    Article  Google Scholar 

  63. Rusch N, Corrigan PW, Todd AR, Bodenhausen GV. Implicit self-stigma in people with mental illness. J Nerv Mental Dis. 2010;198(2):150–3.

    Article  Google Scholar 

  64. Suvorova AV, Belyakov AN, Makhamatova AF, Ustinov AS, Levina OS, Tulupyey AL, et al. Comparison of satisfaction with care between two different models of HIV care delivery in St. Petersburg, Russia. AIDS Care. (in press).

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Acknowledgments

This research was supported by Award Number R01-DA029888 from the National Institute on Drug Abuse (NIDA) and Award Number P30-MH062294 from the National Institute of Mental Health (NIMH). Sarah K. Calabrese was supported by Award Numbers K01-MH103080 and T32-MH020031 from the NIMH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIDA, NIMH, or the National Institutes of Health. The authors are grateful to participants for their generous contribution to the study.

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Calabrese, S.K., Burke, S.E., Dovidio, J.F. et al. Internalized HIV and Drug Stigmas: Interacting Forces Threatening Health Status and Health Service Utilization Among People with HIV Who Inject Drugs in St. Petersburg, Russia. AIDS Behav 20, 85–97 (2016). https://doi.org/10.1007/s10461-015-1100-4

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Keywords

  • Stigma
  • Injection drug use
  • HIV
  • Health
  • Health services
  • Russia