Although it is well established that HIV-related stigma, depression, and lack of social support are negatively associated with health-related quality of life (HRQoL) among people living with HIV (PLH), no studies to date have examined how these psychosocial factors interact with each other and affect HRQoL among incarcerated PLH. We, therefore, incorporated a moderated mediation model (MMM) to explore whether depression mediates the effect of HIV-related stigma on HRQoL as a function of the underlying level of social support. Incarcerated HIV-infected men with opioid dependence (N = 301) were recruited from the HIV units in Kajang prison in Malaysia. Participants completed surveys assessing demographic characteristics, HIV-related stigma, depression, social support, and HRQoL. Results showed that the effect of HIV-related stigma on HRQoL was mediated via depression (a1:β = 0.1463, p < 0.001; b1:β = −0.8392, p < 0.001), as demonstrated by the two-tailed significance test (Sobel z = −3.8762, p < 0.001). Furthermore, the association between social support and HRQoL was positive (β = 0.4352, p = 0.0433), whereas the interaction between HIV-related stigma and depression was negatively associated with HRQOL (β = −0.0317, p = 0.0133). This indicated that the predicted influence of HIV-related stigma on HRQoL via depression had negative effect on HRQoL for individuals with low social support. The results suggest that social support can buffer the negative impact of depression on HRQoL and highlights the need for future interventions to target these psychosocial factors in order to improve HRQoL among incarcerated PLH.
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Joint United Nations Programme on HIV/AIDS. How AIDS changed everything? In. Geneva, Switzerland; 2015
UNAIDS. The Gap Report. In Switzerland; 2014.
Ministry of Health Malaysia. Global AIDS response progress report 2014: Malaysia. In Malaysia, 2014.
Kamarulzaman A. Impact of HIV prevention programs on drug users in Malaysia. J Acquir Immune Defic Syndr. 2009;52(Suppl 1):S17–9.
Todd C, Nassiramanesh B, Stanekzai M, Kamarulzaman A. Emerging HIV epidemics in muslim countries: assessment of different cultural responses to harm reduction and implications for HIV control. Curr HIV/AIDS Rep. 2007;4(4):151–7.
Ngadiman S, Suleiman A, Taib SM, Yuswan F. Malaysia 2014: Country responses to HIV/AIDS. Malaysia: Ministry of Health Malaysia; 2014.
Bazazi A, Crawford F, Zelenev A, Heimer R, Kamarulzaman A, Altice FL. HIV prevalence among people who inject drugs in greater kuala lumpur recruited using respondent-driven sampling. AIDS Behav. 2015;19(12):2347–57.
Choi P, Kavasery R, Desai MM, Govindasamy S, Kamarulzaman A, Altice FL. Prevalence and correlates of community re-entry challenges faced by HIV-infected male prisoners in Malaysia. Int J STD AIDS. 2010;21(6):416–23.
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.
Castro A, Farmer P. Understanding and addressing AIDS-related stigma: from anthropological theory to clinical practice in Haiti. Am J Public Health. 2005;95(1):53–9.
Bachireddy C, Bazazi AR, Kavasery R, Govindasamy S, Kamarulzaman A, Altice FL. Attitudes toward opioid substitution therapy and pre-incarceration HIV transmission behaviors among HIV-infected prisoners in Malaysia: implications for secondary prevention. Drug Alcohol Depend. 2011;116(1–3):151–7.
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.
Ferro E, Wickersham JA, Marcus R, Lee CK, Westergaard RP, Kamarulzaman A, et al. Lack of prescription of antiretroviral therapy to vulnerable populations by Malaysian physicians. In: ID Week. San Francisco, CA: Infectious Diseases Society of America; 2013 pp. [Abstract WE-1206].
Lee R, Kochman A, Sikkema K. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6(4):309–19.
Ferro E, Wickersham J, Marcus R, Kamarulzaman A, Altice F. Lack of prescription of antiretroviral therapy to vulnerable population by Malaysian physicians. In: Infectious Diseases Society of America Meeting. San Francisco, CA: Infectious Diseases Society of America; 2013.
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;12:463.
Li X, Li L, Wang H, Fennie KP, Chen J, Williams AB. Mediation analysis of health-related quality of life among people living with HIV infection in China. Nurs Health Sci. 2015;17(2):250–6.
Westergaard RP, Spaulding AC, Flanigan TP. HIV among persons incarcerated in the US: a review of evolving concepts in testing, treatment and linkage to community care. Curr Opin Infect Dis. 2013;26(1):10–6.
Small W, Wood E, Betteridge G, Montaner J, Kerr T. The impact of incarceration upon adherence to HIV treatment among HIV-positive injection drug users: a qualitative study. AIDS Care. 2009;21(6):708–14.
Briongos Figuero LS, Bachiller Luque P, Palacios Martin T, Gonzalez Sagrado M, Eiros Bouza JM. Assessment of factors influencing health-related quality of life in HIV-infected patients. HIV Med. 2011;12(1):22–30.
Duffy L. Suffering, shame, and silence: the stigma of HIV/AIDS. J Assoc Nurses AIDS Care. 2005;16(1):13–20.
Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London AS, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.
Jin H, Hampton Atkinson J, Yu X, Heaton RK, Shi C, Marcotte TP, et al. Depression and suicidality in HIV/AIDS in China. J Affect Disord. 2006;94(1–3):269–75.
Kagee A, Martin L. Symptoms of depression and anxiety among a sample of South African patients living with HIV. AIDS Care. 2010;22(2):159–65.
Dal-Bo MJ, Manoel AL, Filho AO, Silva BQ, Cardoso YS, Cortez J, et al. Depressive symptoms and associated factors among people living with HIV/AIDS. J Int Assoc Provid AIDS Care. 2015;14(2):136–40.
Zahari MM, Hwan Bae W, Zainal NZ, Habil H, Kamarulzaman A, Altice FL. Psychiatric and substance abuse comorbidity among HIV seropositive and HIV seronegative prisoners in Malaysia. Am J Drug Alcohol Abuse. 2010;36(1):31–8.
Tate D, Paul RH, Flanigan TP, Tashima K, Nash J, Adair C, et al. The impact of apathy and depression on quality of life in patients infected with HIV. AIDS Patient Care STDS. 2003;17(3):115–20.
Jia H, Uphold CR, Wu S, Chen GJ, Duncan PW. Predictors of changes in health-related quality of life among men with HIV infection in the HAART era. AIDS Patient Care STDS. 2005;19(6):395–405.
Shrestha R, Weikum D, Copenhaver M, Altice FL. The influence of neurocognitive impairment, depression, and alcohol use disorders on health-related quality of life among incarcerated, HIV-infected, opioid dependent malaysian men: a moderated mediation analysis. AIDS Behav. 2016;1:1–12.
McDowell TL, Serovich JM. The effect of perceived and actual social support on the mental health of HIV-positive persons. AIDS Care. 2007;19(10):1223–9.
Johnson J, Alloy LB, Panzarella C, Metalsky GI, Rabkin JG, Williams JB, et al. Hopelessness as a mediator of the association between social support and depressive symptoms: findings of a study of men with HIV. J Consult Clin Psychol. 2001;69(6):1056–60.
Silver EJ, Bauman LJ, Camacho S, Hudis J. Factors associated with psychological distress in urban mothers with late-stage HIV/AIDS. AIDS Behav. 2003;7(4):421–31.
Mkangara OB, Wang C, Xiang H, Xu Y, Nie S, Liu L, et al. The univariate and bivariate impact of HIV/AIDS on the quality of life: a cross sectional study in the Hubei Province-Central China. J Huazhong Univ Sci Technol Med Sci. 2009;29(2):260–4.
Simoni JM, Pantalone DW, Plummer MD, Huang B. A randomized controlled trial of a peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women. Health Psychol. 2007;26(4):488–95.
Nargiso JE, Kuo CC, Zlotnick C, Johnson JE. Social support network characteristics of incarcerated women with co-occurring major depressive and substance use disorders. J Psychoact Drugs. 2014;46(2):93–105.
Johnson JE, Esposito-Smythers C, Miranda R Jr, Rizzo CJ, Justus AN, Clum G. Gender, social support, and depression in criminal justice-involved adolescents. Int J Offender Ther Comp Criminol. 2011;55(7):1096–109.
Bajunirwe F, Tisch DJ, King CH, Arts EJ, Debanne SM, Sethi AK. Quality of life and social support among patients receiving antiretroviral therapy in Western Uganda. AIDS Care. 2009;21(3):271–9.
Bekele T, Rourke SB, Tucker R, Greene S, Sobota M, Koornstra J, et al. Direct and indirect effects of perceived social support on health-related quality of life in persons living with HIV/AIDS. AIDS Care. 2013;25(3):337–46.
Galvan FH, Davis EM, Banks D, Bing EG. HIV stigma and social support among African Americans. AIDS Patient Care STDS. 2008;22(5):423–36.
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.
Mak WW, Cheung RY, Law RW, Woo J, Li PC, Chung RW. Examining attribution model of self-stigma on social support and psychological well-being among people with HIV+/AIDS. Soc Sci Med. 2007;64(8):1549–59.
Leslie MB, Stein JA, Rotheram-Borus MJ. The impact of coping strategies, personal relationships, and emotional distress on health-related outcomes of parents living with HIV or AIDS. J Soc Pers Relatsh. 2002;19(1):45–66.
Bui HN, Morash M. The impact of network relationships, prison experiences, and internal transformation on women’s success after prison release. J Offender Rehabil. 2010;49(1):1–22.
Harp KL, Oser C, Leukefeld C. Social support and crack/cocaine use among incarcerated mothers and nonmothers. Subst Use Misuse. 2012;47(6):686–94.
Staton-Tindall M, Royse D, Leukfeld C. Substance use criminality, and social support: an exploratory analysis with incarcerated women. Am J Drug Alcohol Abuse. 2007;33(2):237–43.
Bazazi A, Wickersham J, Wegman M, Pillai V, Culbert G, Shrestha R, et al. Design and implementation of a factorial randomized controlled trial of methadone maintenance therapy and an evidence-based behavioral intervention for incarcerated people living with HIV and opioid dependence in Malaysia. Contemp Clin Trials 2016; (Under review).
Walmsley R. World prison population List (11th Edition). London: International Centre for Prison Studies; 2015.
HIV/STI Section, Disease Control Division, Ministry of Health Malaysia. Global AIDS Response Progress Report Malaysia 2015: Reporting period January 2014 to December 2014.. 2015.
Personal Communication: Malaysian Prison Department. In; 2016.
Bick J, Culbert GJ, Al-Darraji HA, Koh C, Pillai V, Kamarulzaman A, et al. Healthcare resources are inadequate to address the burden of illness among HIV-infected male prisoners in Malaysia. 2016.
Culbert GJ, Pillai V, Bick J, Al-Darraji HA, Wickersham JA, Wegman MP, et al. Confronting the HIV, tuberculosis, addiction, and incarceration syndemic in southeast Asia: lessons learned from Malaysia. J Neuroimmune Pharmacol. 2016;11(3):446–55.
Brislin RW. Back-translation for cross-cultural research. J Cross Cult Psych. 1970;1:185–216.
Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24(6):518–29.
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.
Holzemer WL, Human S, Arudo J, Rosa ME, Hamilton MJ, Corless I, et al. Exploring HIV stigma and quality of life for persons living with HIV infection. J Assoc Nurses AIDS Care. 2009;20(3):161–8.
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.
Cook JA, Cohen MH, Burke J, Grey D, Anastos K, Kirstein L, et al. Effects of depressive symptoms and mental health quality of life on use of highly active antiretroviral therapy among HIV-seropositive women. J Acquir Immune Defic Syndr. 2002;30(4):401–9.
Low-Beer S, Chan K, Yip B, Wood E, Montaner JS, O’Shaughnessy MV, et al. Depressive symptoms decline among persons on HIV protease inhibitors. J Acquir Immune Defic Syndr. 2000;23(4):295–301.
Jeyaseelan L, Kumar S, Mohanraj R, Rebekah G, Rao D, Manhart LE. Assessing HIV/AIDS stigma in south India: validation and abridgement of the Berger HIV stigma scale. AIDS Behav. 2013;17(1):434–43.
Franke MF, Muñoz M, Finnegan K, Zeladita J, Sebastian JL, Bayona JN, et al. Validation and abbreviation of an HIV Stigma scale in an adult spanish-speaking population in Urban Peru. AIDS Behav. 2010;14(1):189–99.
Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32(6):705–14.
Hays RD, Sherbourne CD, Mazel RM. The rand 36-item health survey 1.0. Health Econ. 1993;2(3):217–27.
IBM Corp. IBM SPSS statistics for Windows, Version 23. Armonk, NY: IBM Corp; 2015.
Baron RM, Kenny DA. The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. J Pers Soc Psychol. 1986;51(6):1173.
Sobel ME. Asymptotic confidence intervals for indirect effects in structural equation models. Sociol Methodol. 1982;1982(13):290–312.
Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behav Res Methods Instrum Comput. 2004;36(4):717–31.
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.
Oguntibeju OO. Quality of life of people living with HIV and AIDS and antiretroviral therapy. HIV/AIDS (Auckland, NZ). 2012;4:117–24.
McInerney PA, Ncama BP, Wantland D, Bhengu BR, McGibbon C, Davis SM, et al. Quality of life and physical functioning in HIV-infected individuals receiving antiretroviral therapy in KwaZulu-Natal, South Africa. Nurs Health Sci. 2008;10(4):266–72.
Safren SA, Hendriksen ES, Smeaton L, Celentano DD, Hosseinipour MC, Barnett R, et al. Quality of life among individuals with HIV starting antiretroviral therapy in diverse resource-limited areas of the world. AIDS Behav. 2012;16(2):266–77.
Igumbor J, Stewart A, Holzemer W. Comparison of the health-related quality of life, CD4 count and viral load of AIDS patients and people with HIV who have been on treatment for 12 months in rural South Africa. SAHARA J. 2013;10(1):25–31.
Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. New York: Guilford Press; 2013.
Grov C, Golub SA, Parsons JT, Brennan M, Karpiak SE. Loneliness and HIV-related stigma explain depression among older HIV-positive adults. AIDS Care. 2010;22(5):630–9.
Nachega JB, Morroni C, Zuniga JM, Sherer R, Beyrer C, Solomon S, et al. HIV-related stigma, isolation, discrimination, and serostatus disclosure: a global survey of 2035 HIV-infected adults. Journal of the International Association of Physicians in AIDS Care (Chicago, Ill : 2002). 2012;11(3):172–8.
Scheyett A, Parker S, Golin C, White B, Davis C, Wohl D. HIV-infected prison inmates: depression and implications for release back to communities. AIDS Behav. 2010;14(2):300–7.
Fazel S, Seewald K. Severe mental illness in 33 588 prisoners worldwide: systematic review and meta-regression analysis. Br J Psychiatry. 2012;200(5):364–73.
Ciesla JA, Roberts JE. Meta-Analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158(5):725–30.
Chong ST, Mohamad M, Er A. The mental health development in Malaysia: history, current issue and future development. Asian Soc Sci. 2013;9(6):1–8.
Wickersham JA, Zahari MM, Azar MM, Kamarulzaman A, Altice FL. Methadone dose at the time of release from prison significantly influences retention in treatment: implications from a pilot study of HIV-infected prisoners transitioning to the community in Malaysia. Drug Alcohol Depend. 2013;132(1–2):378–82.
Rich JD, McKenzie M, Larney S, Wong JB, Tran L, Clarke J, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet. 2015;386:350–9.
Mukherjee TI, Wickersham JA, Desai MM, Pillai V, Kamarulzaman A, Altice FL. Factors associated with interest in receiving prison-based methadone maintenance therapy in Malaysia. Drug Alcohol Depend. 2016;164:120–7.
Turner CF, Rogers SM, Hendershot TP, Miller HG, Thornberry JP. Improving representation of linguistic minorities in health surveys. Public Health Rep. 1996;111(3):276–9.
This work was supported by Grants from the National Institute on Drug Abuse for research (R01 DA025943 and R01 DA041271 to FLA), for career development (NIDA K24 DA017072 to FLA; K02 DA033139 to MMC), and for training (T32GM07205, F30DA039716 to ARB).
Conflicts of interest
The authors have no conflicts of interest to disclose.
The protocol for the parent study was approved by institutional review boards at the University Malaya Medical Centre and Yale University. The protocol was also reviewed and approved by the Office of Human Research Protection at the US Department of Health and Human Services (DHHS) as it involved federally-funded research with prisoners. 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 was obtained from all individual participants included in the study.
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Shrestha, R., Copenhaver, M., Bazazi, A.R. et al. A Moderated Mediation Model of HIV-Related Stigma, Depression, and Social Support on Health-Related Quality of Life among Incarcerated Malaysian Men with HIV and Opioid Dependence. AIDS Behav 21, 1059–1069 (2017). https://doi.org/10.1007/s10461-017-1693-x