Pathways to Health: an Examination of HIV-Related Stigma, Life Stressors, Depression, and Substance Use
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.
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.
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.
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.
KeywordsHIV-related stigma Stressful life events HIV Depression Substance use
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
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.
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.
- 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.Goodenow MM. Director’s update: why is U=U a game changer?: Office of AIDS Research National Institutes of Health; 2018.Google Scholar
- 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.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.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.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.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.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
- 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.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.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.Link BG, Phelan JC. Stigma and its public health implications. Lancet. 2006;367(9509):528–9.Google Scholar
- 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.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.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.Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6(4):309–19.Google Scholar
- 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.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.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
- 24.Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539–45.Google Scholar
- 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
- 28.Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298(14):1685–7.Google Scholar
- 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.Sinha R. Chronic stress, drug use, and vulnerability to addiction. Ann N Y Acad Sci. 2008;1141(1):105–30.Google Scholar
- 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
- 33.Rabkin JG. HIV and depression: 2008 review and update. Curr HIV/AIDS Rep. 2008;5(4):163–71.Google Scholar
- 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.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.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.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.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.
- 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
- 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.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.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.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.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.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.Muthén L, Muthén B. Mplus Version 7. Los Angeles, CA; 1998.Google Scholar
- 49.UNAIDS. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS; 2014.Google Scholar
- 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.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.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.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
- 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.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.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.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
- 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.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.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.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.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.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
- 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.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.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.
- 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