In this diverse sample of PLHA in Los Angeles County, approximately one-third of participants reported experiencing high levels of internalized HIV stigma. We found that respondents experiencing high levels of stigma had over four times the odds of reporting poor access to care. Mental health attenuated the association between stigma and suboptimal ART adherence, suggesting that the relationship between stigma and ART adherence is mediated by mental health. Additional prospective longitudinal studies in larger samples are needed to better understand possible mediators of the associations between HIV stigma and access to care and ART adherence. This may in turn help to guide interventions to improve HIV care and health outcomes for PLHA.
Our findings demonstrate that in a diverse and underserved sample of PLHA, poor self-reported access to medical care is strongly associated with experiencing HIV stigma. It did not appear that mental health or other predisposing, enabling, or clinical need factors explained this association. Poor self-reported access to care could also itself be a result of the perceived discrimination and social inequities that are central to the process of stigma. In this scenario, it is possible that an omitted variable that reflects perceived discrimination and social disadvantage may influence both experiences of stigma and self-reported access to care.
Interestingly, we found that stigma was not strongly associated with having a regular source of HIV care in our sample after controlling for predisposing, enabling, and clinical need characteristics. One explanation for this may be that stigma has less of a role in an established patient-provider relationship compared with other factors such as patient-provider concordance by race or gender, satisfaction, communication, and trust.32,33
Alternatively, we may have failed to identify an association because the percentage of the sample reporting no regular source of HIV care was small (10.5%).
Our data suggest that HIV stigma may be associated with suboptimal ART adherence, and this relationship may be partially mediated by lower mental health status. Specifically, lower MCS was associated with suboptimal adherence, and when MCS was included in the mediation model, the association with stigma was attenuated and no longer significant. This is consistent with previously published studies that demonstrate that stigma and depression influence ART adherence.11,15
However, the interrelationship and pathways between stigma and other factors known to be associated with adherence such as social support,34
and attitudes toward medication36
need to be further delineated in future studies in order to identify targets for effective intervention programs.
In our study, PLHA diagnosed within the last 5 years reported higher levels of stigma than those living longer with the disease, suggesting that stigma may attenuate over time. Future longitudinal studies should examine how HIV stigma changes over time and with disease progression, as many PLHA may live decades with this chronic disease. This finding also suggest that addressing internalized stigma and its potential impact on HIV treatment may be particularly important to incorporate into programs targeting recently diagnosed PLHA.
There were several limitations to this study. First, as our data were cross-sectional, causality between internalized HIV stigma and our outcomes cannot be established. Also, potentially important covariates such as social inequality, social support, and self-efficacy were not observed in our models. However, our study does provide valuable information about the strong association between stigma and self-reported access to care and adherence, and directs future work to further delineate these relationships. Second, our study sample may be biased (ascertainment bias) toward people who have already partially engaged in medical care or social services, and it may underestimate the association between poor access and internalized stigma for the most vulnerable group of PLHA who do not access care or HIV services at all. Finally, although we successfully recruited a sample of diverse PLHA, non-English speakers such as Latino/as and Asian Americans were underrepresented in our sample.
Despite these limitations, our study provides important information about the association between internalized HIV stigma and self-reported access to medical care and ART adherence. Prospective studies that include more objective measures of access to care, such as utilization of subspecialty care, HIV care, preventive care, and emergency/hospital care, would help us to better understand the access needs of underserved PLHA over the course of their disease. Prospective studies could also help us to examine the directionality of the association between stigma and access to care, as well as to identify additional factors that may mediate or moderate this relationship. Finally, such studies could enable us to examine changes in stigma and its contribution to health care and health outcomes throughout the disease trajectory.