Abstract
Mental health-related stigma is a prominent barrier to improved mental health outcomes globally and may be particularly harmful to populations with other stigmatized identities. We aimed to understand intersectional depression- and HIV-related stigma among people with HIV (PWH) entering HIV care in Cameroon. Using baseline data from a cohort of PWH entering HIV care in Cameroon between 2019 and 2020, we characterized depression- and HIV-related stigma in the population overall and by sociodemographic sub-group. We also explored substantively meaningful variation in stigma endorsement by depressive symptom severity (Patient Health Questionnaire-9 [PHQ-9]) and causal attribution of depression. Among those with elevated depressive symptoms (PHQ-9 scores > 4), we estimated the association between stigma type and depressive symptom severity using binomial regression. Among 398 participants, 49% endorsed low HIV- and depression-related stigma (N = 195), 10% endorsed high HIV- and depression-related stigma (N = 38), 29% endorsed high depression-related stigma only (N = 116), and 12% endorsed high HIV-related stigma only (N = 49). Respondents with and without heightened depressive symptoms commonly believed depressive symptoms were caused by HIV (N = 140; 32.9%). Among those with elevated depressive symptoms, the prevalence of moderate to severe symptoms was higher among those endorsing high HIV-related stigma only (prevalence ratio 1.55; 95% confidence interval: 1.01, 2.37) compared to those reporting low HIV- and depression-related stigma. HIV- and depression-related stigma are both common among PWH entering HIV care in Cameroon. The consistent association between HIV-related stigma and poor psychosocial well-being among people with HIV necessitates the urgent scale-up of evidence-based HIV-related stigma interventions specifically.
Keywords: Mental health, Stigma, HIV, Cameroon, Depression
Introduction
Stigma has been broadly defined as the “co-occurrence of labeling, stereotyping, separation, status loss and discrimination” that stems from inequity [1]. Stigma is perpetuated and perceived by individuals, systems and communities; it has yielded widespread consequences, including adverse physical and mental health outcomes, for a vast array of populations, including people with chronic conditions such as depression and HIV [2–6]. While stigma is varied, changing and modifiable — with a growing number of evidence-based stigma reduction interventions [7, 8] — individuals with multiple or intersecting stigmatized identities may be particularly susceptible to the negative consequences of stigma [2]. Yet, intersectional stigma, or “the convergence of multiple stigmatized identities within a person or group” (e.g., mental health and HIV-related stigmas), and the effects of different types of intersectional stigma remain poorly understood and understudied [9].
Mental health disorders account for 15% of years lived with disability globally [10]. Research from high-income countries suggests mental health-related stigma and discrimination are prominent barriers to improved mental health outcomes [11, 12] and are associated with increased risk of unemployment, unstable housing, social isolation, poor quality of health and unmet mental health needs among individuals with mental ill health [13–16]. As in many other geographic settings, stigmatizing cultural or societal norms related to mental health disorders have been documented throughout sub-Saharan Africa, where access to evidence-based mental health care also remains severely limited [17–19]. It has been posited that increasing awareness about the causes and biological mechanisms of poor mental health can both reduce mental health-related stigma and improve mental health outcomes [55–57]. However, little is known about the relationship between mental health-related stigma and discrimination, knowledge regarding the causes and mechanisms of poor mental health, and psychosocial well-being in sub-Saharan Africa and among PWH.
Over the past four decades, Africa has borne a disproportionate burden of the HIV epidemic, with an estimated 25.6 million — out of 38.4 million total (i.e., 66%) — PWH living in the region in 2021 [20]. HIV-related stigma and discrimination have been persistent impediments to improved HIV treatment and care outcomes and achievement of global HIV targets since the onset of the epidemic [21, 22]. While estimates of HIV-related stigma and discrimination are lower in Africa when compared to other geographic settings [23], HIV-related stigma and discrimination continue to impede HIV testing uptake [24], delay linkage to care and anti-retroviral therapy initiation [25, 26] and hinder retention in care and viral suppression over time on the continent [22, 25, 27].
For PWH with co-occurring mental health disorders, HIV- and mental health-related stigmas may interact to further exacerbate poor HIV treatment and mental health outcomes [2, 22, 28]. Using an intersectional framework that “acknowledges intra-category diversity and [helps] to investigate relationships between and among dynamic categories of difference” can yield critical insight into advancing health outcomes for PWH [2, 29]. Yet, research into the prevalence, correlates, and consequences of intersectional mental health and HIV-related stigma among PWH is scant. This paucity of data contributes to a poor understanding of the relationships among multiple forms of stigma and how to address intersectional stigma to most efficiently and effectively improve mental and physical health outcomes among PWH.
In this exploratory work, we aimed to quantify externalized depression-related stigma and characterize its intersection with anticipated HIV-related stigma among a sample of PWH entering HIV care in Cameroon. We also aimed to characterize substantively meaningful differences in the types of HIV- and depression-related stigma endorsed by sociodemographic sub-groups, the severity of depressive symptoms endorsed, and the causal attribution of depressive symptoms. Our overall goal was to better understand the landscape of intersectional HIV- and depression-related stigma among PWH in Cameroon and potential sub-groups who may be most vulnerable to poor outcomes associated with intersectional stigma or who may be most likely to perpetuate stigmatizing beliefs related to HIV or depression and may therefore benefit most from stigma-reduction interventions.
Methods
We used data from a cross-sectional study, previously described, conducted with a cohort of PWH newly entering HIV care — including those who were newly diagnosed and those known to be living with HIV who may have previously been in care elsewhere — at three urban HIV treatment facilities in Cameroon [30, 31]. Briefly, a trained research team member fluent in English and French conducted structured interviews among those newly entering HIV care between June 2019 and March 2020. Interviews were conducted in the participants’ language of choice and ascertained participants’ sociodemographic background, symptoms of depression and other mental health disorders, anticipated HIV-related stigma, and mental-health-related stigma.
Measures
Depression-Related Stigma
We used an adapted version of the Stigma in Global Context- Mental Health Study Depression vignette measure (see Electronic Supplementary Material) [32–34] that has been used globally and recently validated in Malawi [35]. This tool uses a vignette that describes the feelings and behaviors of an individual experiencing depressive disorder symptoms to explore respondents’ perceptions of the causes and effects of the individual’s described symptoms. Importantly, the vignette only describes the individual’s behaviors and symptoms (e.g., feeling down, sad mood, lack of enjoyment, difficulty completing tasks, low energy) but does not explicitly state the individual has been diagnosed with or is experiencing depression. This tool stems from work completed in 2000 by Martin, Pescosolido, and Tuch, which explored the relationship between five fundamental factors and mental health stigma (i.e., respondent’s willingness to interact with those exhibiting symptoms of mental illness) [36]. The five factors explored included the nature of the behavior described, causal attribution of the behavior’s source, perceived dangerousness of the person, the label of “mental illness,” and sociodemographics of respondents. Ultimately, the authors demonstrated that stigma towards individuals with distinct mental health disorders varied according to individuals’ perceptions of the root cause of the mental health disorder symptoms (e.g., those who believed structural factors such as stress were the cause of individuals’ symptoms were more willing to interact with someone experiencing depressive symptoms than those who believed factors such as bad character were the cause of individuals’ symptoms) [36]. This groundwork was used to inform the development of the original Stigma in Global Context-Mental Health Study Depression tool which included 75 separate questions and captured two distinct domains of mental-health-related stigma — stigma as a lack of knowledge and stigma as prejudice [32].
In the adapted version of this tool used in the present study (see Electronic Supplementary Material), respondents were asked if “Marie’s” (the name given to a fictional individual described in the vignette) symptoms and behaviors were caused by HIV, depression, stress, poverty, schizophrenia, asthma, normal ups and downs, or something else to ascertain a measure of the respondent’s causal attribution of depression. Only one response could be endorsed. Participants were then asked four questions related to stigma as prejudice — specifically whether (1) being around Marie would make the respondent uncomfortable; (2) Marie should be embarrassed about her situation; (3) members of Marie’s family would be better off if her situation was kept secret; and (4) Marie would lose friends if others found out about her situation. Response options ranged from “Strongly Disagree” to “Strongly Agree” on a 5-point Likert scale. While these questions have recently been shown to capture aspects of stigma related to disclosure carryover, or the role of disclosure on others (i.e., family), and negative affect, or negative feelings or attitudes towards those with depressive symptoms [35], we created an overall depression-related stigma score based on the proportion of endorsed items. Responses of “Agree” or “Strongly Agree” were considered an endorsement of each statement. Overall scores were dichotomized at the median possible score to represent those with low (i.e., endorsement of less than or equal to 2/4 items [referent]) versus high (i.e., endorsement of 3 or 4 items) depression-related stigma.
Anticipatory HIV-Related Stigma
Anticipatory HIV-related stigma was assessed with 12 yes/no items, which asked participants if they were worried about adverse outcomes related to others finding out about their HIV status (e.g., If others know or suspect that you have HIV, your family might treat you differently), as previously described (see Electronic Supplementary Material) [4]. These items, which were developed from the concept described by Earnshaw and Chaudoir [37], have been previously used to assess anticipatory HIV-related stigma in PWH in the Global South [38]. The 12th question asked individuals if there was any “other” thing they were concerned might happen if others found out about their HIV status. Responses to this question were recategorized if they fit into a pre-existing response option. A total anticipatory HIV-related stigma score was created based on the proportion of endorsed items among all items that the participant was eligible to answer (e.g., participants without a romantic partner were not eligible to answer questions about their romantic partner) such that potential scores ranged from 0% endorsement to 100% endorsement. Scores were dichotomized at the median possible score to represent those with low (i.e., endorsement of less than or equal to 50% of eligible items [referent]) versus high (i.e., endorsement of more than 50% of eligible items) anticipatory HIV-related stigma.
Intersectional Stigma
A categorical variable was created to describe whether an individual endorsed low HIV- and depression-related stigma (referent), high HIV-related stigma only, high depression-related stigma only, or high HIV- and depression-related stigma using the dichotomous depression- and HIV-related stigma measures described above.
Depressive Symptoms
We used the Patient Health Questionnaire-9 (PHQ-9) [39], which has been validated and used among PWH in sub-Saharan Africa, including in Cameroon, to assess symptoms of depression [40–43]. Possible scale scores range from 0 to 27, with scores greater than 4 indicative of elevated depressive symptoms and scores greater than 9 considered indicative of moderate to severe symptoms [43, 44]. Cronbach’s alpha from the current study was 0.81.
Sociodemographics
Sociodemographic data included gender, age, education, relationship status, number of children, and employment and were captured through participant self-report.
Statistical Analyses
Individuals missing data on HIV- or depression-related stigma were excluded from the current analyses. Among remaining individuals, we characterized endorsement of the four distinct levels of HIV- and depression-related stigma described above in the population overall and stratified by sociodemographic sub-groups using counts and proportions. We also described endorsement of each of the four depression-related stigma questions and participants’ causal attribution of depressive symptoms, overall and stratified by stigma endorsement type (to explore if correctly identifying the root cause of depressive symptoms was associated with lower depression-related stigma) and depressive symptom severity (to explore if those endorsing greater HIV- and depression-related stigma also endorsed more severe depressive symptoms) using counts and proportions. Among those with elevated depressive symptoms, we estimated the association between stigma type and endorsement of moderate to severe depressive symptoms using unadjusted binomial regression models to estimate prevalence ratios and prevalence differences. Regression analyses were restricted to those with elevated depressive symptoms only to ensure participants were directly susceptible to the potential negative effects of both forms of stigma (i.e., were living with both HIV and heightened depressive symptoms).
Results
Study Population
There were 426 individuals enrolled between June 2019 and March 2020, 28 of whom were excluded from the present analysis because they were missing data on the endorsement of either HIV-related stigma, depression-related stigma, or both. Of the 398 included individuals, a majority were female (n = 236; 59.3%), aged 21–39 (n = 233; 58.5%), in a relationship (n = 235; 59.0%), and employed (n = 255; 64.1%; Table 1).
Table 1.
Sociodemographic characteristics and endorsement of HIV- and depression-related stigma among a cohort of 398 PWH entering HIV care in Cameroon
| Total (n = 398) |
Low HIV- and depression-related stigma (n = 195) |
High HIV-related stigma only (n = 49) |
High depression-related stigma only (n = 116) |
High HIV- and depression-related stigma (n = 38) |
|
|---|---|---|---|---|---|
| n (col %) | n (row %) | n (row %) | n (row %) | n (row %) | |
| Gender | |||||
| Male | 162 (40.7) | 85 (52.5) | 18 (11.1) | 43 (26.5) | 16 (9.9) |
| Female | 236 (59.3) | 110 (46.6) | 31 (13.1) | 73 (30.9) | 22 (9.3) |
| Age | |||||
| 21–39 | 233 (58.5) | 103 (44.2) | 35 (15.0) | 65 (27.9) | 30 (12.9) |
| 40+ | 165 (41.5) | 92 (55.8) | 14 (8.5) | 51 (30.9) | 8 (4.8) |
| Education | |||||
| None | 26 (6.5) | 16 (61.5) | 3 (11.5) | 6 (23.1) | 1 (3.8) |
| Primary | 207 (52.0) | 108 (52.2) | 24 (11.6) | 60 (29.0) | 15 (7.2) |
| ≥Secondary | 165 (41.5) | 71 (43.0) | 22 (13.3) | 50 (30.3) | 22 (13.3) |
| Relationship status | |||||
| Single | 163 (41.0) | 79 (48.5) | 25 (15.3) | 46 (28.2) | 13 (8.0) |
| Partnered | 235 (59.0) | 116 (49.4) | 24 (10.2) | 70 (29.8) | 25 (10.6) |
| Number of children | |||||
| 0 | 76 (19.2) | 24 (31.6) | 16 (21.1) | 20 (26.3) | 16 (21.1) |
| ≥1 | 320 (80.8) | 171 (53.4) | 32 (10.0) | 95 (29.7) | 22 (6.9) |
| Employment | |||||
| No paid work | 143 (35.9) | 74 (51.7) | 22 (15.4) | 36 (25.2) | 11 (7.7) |
| Paid work | 255 (64.1) | 121 (47.5) | 27 (10.6) | 80 (31.4) | 27 (10.6) |
Missing: number of children = 2
Depression-Related Stigma
Nearly all participants (N = 374; 94.0%) endorsed at least one of the four depression-related stigma items, with 80 individuals (20.1%) endorsing one item, 140 (35.2%) endorsing two items, 114 (28.6%) endorsing three items, and 37 (9.3%) endorsing all four items; three individuals (0.8%) endorsed three out of the four items but refused to respond to the fourth item. The most commonly endorsed depression-related stigma item was that “Members of Marie’s family would be better off if Marie’s situation was kept secret” (N = 250; 63.0%), followed by “If people found out about Marie’s situation, Marie would lose some of her friends” (N = 242; 60.8%; Fig. 1). When asked about the cause of Marie’s depressive symptoms, approximately one-third of individuals cited HIV as the cause (N = 133; 33.4%), 21% endorsed stress as the cause (N = 85), 13% endorsed depression as the cause (N = 53), and 12% endorsed poverty (N = 48). Overall, 13% of respondents (N = 53) endorsed other causes, including normal ups and downs (N = 24) and asthma (N = 6), and 26 individuals (6.5%) said they did not know the cause of Marie’s symptoms (Table 2). HIV was the most commonly cited cause of Marie’s depressive symptoms among those with and without heightened depressive symptoms (Table 2).
Fig. 1.
Endorsement of depression-related stigma items among 398 PWH entering HIV care in Cameroon
Table 2.
Causal attribution of depressive symptoms among 398 PWH entering HIV care in Cameroon from 2019–2020, overall and stratified by depressive symptom severity
| Causal attribution | Total | Severity of depressive symptoms | ||
|---|---|---|---|---|
| (n = 398) | None/minimal (n = 205) |
Mild (n = 112) |
Moderate to severe (n = 81) |
|
| n (col %) | n (col %) | n (col %) | n (col %) | |
| HIV | 133 (33.4) | 65 (31.7) | 37 (33.0) | 31 (38.3) |
| Stress | 85 (21.4) | 42 (20.5) | 27 (24.1) | 16 (19.8) |
| Depression | 53 (13.3) | 29 (14.1) | 10 (8.9) | 14 (17.3) |
| Poverty | 48 (12.1) | 21 (10.2) | 17 (15.2) | 10 (12.3) |
| Other | 53 (13.3) | 33 (16.1) | 14 (12.5) | 6 (7.4) |
| Don’t know | 26 (6.5) | 15 (7.3) | 7 (6.3) | 4 (4.9) |
HIV-Related Stigma
Anticipatory HIV-related stigma in this cohort has been previously described [4, 45]. Briefly, in the current sample, over 80% of individuals endorsed at least one of 12 anticipated HIV-related stigma concerns (N = 321), with 87 individuals (21.9%) endorsing high anticipated HIV-related stigma.
Intersectional HIV- and Depression-Related Stigma
Approximately half (N = 195; 49.0%) of participants reported both low HIV- and low depression-related stigma, nearly a third (N = 116; 29.1%) endorsed high depression-related stigma only, and approximately 10% endorsed high HIV-related stigma only (N = 49; 12.3%) and both high HIV- and high depression-related stigma (N = 38; 9.5%) (Tables 1, 2, 3 and 4). Younger individuals (i.e., aged 21–39 years) and those without children were more likely to endorse both high HIV- and high depression-related stigma and high HIV-related stigma only compared to their counterparts (Table 1). Higher educational attainment was also associated with a higher likelihood of endorsing both high HIV- and high depression-related stigma (Table 1). Endorsement of low HIV- and low depression-related stigma, high HIV- or depression-related stigma only, or high HIV- and depression-related stigma did not meaningfully differ by causal attribution of depressive symptoms (Table 3).
Table 3.
Causal attribution of depressive symptoms and endorsement of HIV- and depression-related stigma among a cohort of 398 PWH entering HIV care in Cameroon between 2019–2020
| Causal attribution | Total (n = 398) n (col %) |
Low HIV- and depression-related stigma (n = 195) n (row %) |
High depression-related stigma only (n = 116) n (row %) |
High HIV-related stigma only (n = 49) n (row %) |
High HIV- and depression-related stigma (n = 38) n (row %) |
|---|---|---|---|---|---|
| HIV | 133 (33.4) | 63 (47.4) | 34 (25.6) | 18 (13.5) | 18 (13.5) |
| Stress | 85 (21.4) | 47 (55.3) | 27 (31.8) | 8 (9.4) | 3 (3.5) |
| Depression | 53 (13.3) | 22 (41.5) | 18 (34.0) | 9 (17.0) | 4 (7.5) |
| Poverty | 48 (12.1) | 23 (47.9) | 16 (33.3) | 3 (6.3) | 6 (12.5) |
| Other | 53 (13.3) | 24 (45.3) | 15 (28.3) | 7 (13.2) | 7 (13.2) |
| Don’t know | 26 (6.5) | 16 (61.5) | 6 (23.1) | 4 (15.4) | 0 (0.0) |
Table 4.
HIV- and depression-related stigma and depressive symptom severity among a cohort of 398 PWH entering HIV care in Cameroon between 2019–2020
| Total | Severity of depressive symptoms | |||
|---|---|---|---|---|
| (n = 398) | None/minimal (n = 205) |
Mild (n = 112) |
Moderate to severe (n = 81) |
|
| n (col %) | n (row %) | n (row %) | n (row %) | |
| Low HIV- and depression-related stigma | 195 (49.0) | 111 (56.9) | 53 (27.2) | 31 (15.9) |
| High Depression-related stigma only | 116 (29.1) | 58 (50.0) | 36 (31.0) | 22 (19.0) |
| High HIV-related stigma only | 49 (12.3) | 21 (42.9) | 12 (24.5) | 16 (32.7) |
| High HIV- and depression-related stigma | 38 (9.5) | 15 (39.5) | 11 (28.9) | 12 (31.6) |
Stigma Type and Endorsement of Moderate to Severe Depressive Symptoms
Symptoms of moderate to severe depression were more prevalent among those reporting high HIV-related stigma only compared to those reporting low HIV- and depression-related stigma (Tables 4 and 5). In those with elevated depressive symptoms (N = 193), the prevalence of moderate to severe symptoms among those endorsing high HIV-related stigma only was 1.55 times (95% confidence interval [CI]: 1.01, 2.37) the prevalence observed among those with low HIV- and depression-related stigma– a difference of 20% points on the absolute scale (95% CI: −1, 41). Symptoms of moderate to severe depression were also marginally more prevalent among those reporting high HIV- and depression-related stigma compared to those reporting low HIV- and depression-related stigma. The prevalence of depressive symptoms among those with high HIV- and depression-related stigma was 1.41 times the prevalence (95% CI: 0.87, 2.29), a difference of 16% points on the absolute scale (95% CI: −8, 38). The prevalence of moderate to severe depressive symptoms was similar among those endorsing high depression-related stigma only and those endorsing low HIV- and depression-related stigma.
Table 5.
Associations between levels of HIV- and depression-related stigma and symptoms of moderate to severe depression among 193 PWH with elevated depressive symptoms who are entering HIV care in Cameroon
| Moderate to severe depressive symptoms | ||
|---|---|---|
| Prevalence ratio (95% confidence interval) | Prevalence difference (95% confidence interval) | |
| Low HIV- and depression-related stigma | ref | ref |
| High depression-related stigma only | 1.03 (0.67, 1.58) | 0.01 (−0.15, 0.17) |
| High HIV-related stigma only | 1.55 (1.01, 2.37) | 0.20 (−0.01, 0.41) |
| High HIV- and depression-related stigma | 1.41 (0.87, 2.29) | 0.16 (−0.08, 0.38) |
Discussion
We explored intersectional HIV- and depression-related stigma among PWH newly entering HIV care in Cameroon and the relationship between these types of stigmas and the prevalence of moderate to severe depressive symptoms among those with elevated depressive symptoms. Approximately 20% of PWH entering HIV care reported high HIV-related stigma, while nearly twice as many (i.e., ~ 40%) endorsed high depression-related stigma (10% endorsed both). Among those with elevated depressive symptoms, the prevalence of moderate to severe symptoms was greater among those endorsing high HIV- and depression-related stigma but greatest among those endorsing high HIV-related stigma only (compared to those reporting low HIV- and depression-related stigma), suggesting HIV-related stigma continues to inhibit the emotional well-being of those entering HIV care four decades into the HIV epidemic.
Depression-related stigma was highly prevalent in this population of people entering HIV care, as has been demonstrated in related populations in a growing body of research [35, 46–51]. For example, in Malawi, Dussault and colleagues estimated that 49% of 688 individuals with elevated symptoms of depression reported high depression-related stigma [35]. In Uganda, Rasmussen and colleagues estimated that 75% of individuals believed most others in their village would be unwilling for a family member to marry someone with depressive symptoms, and 40% believed most others in their village felt someone with depressive symptoms would bring shame on their family [47]. Though varied slightly, these results broadly align with our findings that nearly 40% of individuals entering HIV care in Cameroon endorsed high depression-related stigma, and over 60% believed the family members of someone with symptoms of depression would be better off if that individual’s situation were kept private.
Interestingly, among those with heightened depressive symptoms, there was no observed relationship between endorsement of moderate to severe depressive symptoms (versus mild) and high depression-related stigma only (versus low depression- and HIV-related stigma). Mental health-related stigma and its relationship with poor mental health remains poorly understood, particularly among those with other stigmatized identities such as PWH and among those in resource-constrained settings. It’s possible the lack of observed relationship is related to the type of depression-related stigma measured (externalized stigma toward a fictionalized individual) and may have differed had we measured internalized or experienced depression-related stigma. Future studies should aim to explore the relationship between varying types of depression-related stigma and depressive symptom severity.
Few evidence-based mental health-related stigma interventions have been identified, particularly in resource-constrained settings [52]. In a 2016 review, Thornicroft and colleagues found just 13 studies assessing mental health-related stigma interventions in middle-income countries and no studies from low-income countries [52]. Of the 13 studies from middle-income countries, mixed evidence was observed for interventions’ effects on stigma-related knowledge and attitudinal outcomes. More recently, Jae Lee and colleagues have demonstrated modest improvements in mental health-related stigma outcomes following a community-led theatrical intervention aimed at reducing mental health stigma in Uganda [53]. Mutiso and colleagues also demonstrated the benefit of using the World Health Organization’s mhGAP Intervention Guide, designed to inform clinical decision-making for mental, neurological, and substance use disorders in non-specialized health settings, on reducing mental health-related stigma in Kenya [54, 55]. Additional research is needed to identify other efficacious mental health stigma reduction interventions and ways to effectively scale existing evidence-based interventions in the Global South.
HIV was the most commonly cited cause of depressive symptoms in the mental health stigma vignette used in this study, even among participants reporting elevated symptoms of depression. Previously, researchers have posited that mental health-related stigma can be minimized by increasing population- or individual-level knowledge about mental health disorders as neurobiological disorders or by promoting mental disorders as ‘diseases like any other’ [56–58]. However, evidence supporting the effectiveness of this approach to stigma reduction remains lacking, with some studies showing the approach creates harm [56]. For example, Pescosolido and colleagues found that holding a neurobiological belief about the cause of mental illness increased the odds of having a stigmatizing reaction to someone with mental illness [56]. Moreover, findings from work by Watt and colleagues that explores the potential impact of an HIV-related stigma intervention suggest a persistent “know-do” gap, whereby the intervention increased knowledge regarding HIV and readiness to accept an HIV diagnosis but did not minimize interpersonal distancing towards PWH [59]. In line with these and other findings, our work found that those who correctly identified depression as the cause of Marie’s symptoms were just as likely to endorse high depression-related stigma as those who thought other factors, including HIV and poverty, caused Marie’s symptoms. Given the study population was comprised of individuals newly entering HIV care, it is not surprising that a large proportion of individuals stated Marie’s symptoms and behaviors were likely a result of HIV. Jointly, this information suggests ‘disease like any other’ messaging and related interventions that simply aim to increase knowledge may be ineffective for adequately addressing depression-related stigma among PWH who are likely to identify HIV as the root cause of one’s depressive symptoms.
Endorsement of depressive symptoms was heightened among individuals reporting high HIV-related stigma only and those reporting high HIV- and depression-related stigma, and lower among those reporting high depression-related stigma only and those reporting low HIV- or depression-related stigma. The adverse mental and physical health effects of HIV-related stigma have been well documented across unique settings, populations, and time [4, 21, 60–62]. In recent work published by Mugo and colleagues, HIV-related stigma was found to be associated with depression, HIV treatment non-adherence, and viral non-suppression in a sample of youth living with HIV in Kenya [63]. While such findings are common throughout the literature, little is known about how the effects of HIV-related stigma might change over time as individuals engage, disengage, and reengage in HIV care. Our results suggest that HIV-related stigma may be particularly salient at entry into care. Future work is needed to longitudinally explore intersectional HIV- and depression-related stigma across individuals’ HIV care trajectories. Such research could provide a more nuanced understanding of how distinct types of stigma influence both short and long-term mental health and HIV treatment outcomes.
Finally, our findings suggest that younger individuals, those without children, and those with more formal education may be more likely to endorse intersectional HIV- and depression-related stigma compared to their counterparts. While intersectional HIV- and depression-related stigma remains largely unexplored in the literature, separate bodies of research on HIV-related and mental health-related stigma demonstrate a lack of consistency regarding the direction and magnitude of association between sociodemographic characteristics and these types of stigma [64, 65]. While we do not posit that there is a causal relationship between age, child rearing, formal education and intersectional stigma (as it is likely these sociodemographic factors are correlated and the observed relationship could be mediated or confounded by several factors such as time since diagnosis with HIV) — we do believe these findings can inform specific stigma reduction interventions for people entering HIV care in Cameroon. More specifically, younger individuals, those without children, and those with more formal education should be engaged in the design of stigma reduction interventions to ensure these programs, services, or other forms of support are accessible to and meet the unique needs of these individuals.
This study has limitations worth noting. First, we ascertained distinct types of HIV- and depression-related stigma. The HIV-related stigma measure, which has not been validated in Cameroon or the Global South more broadly, captures anticipated stigma or expectations of stigmatizing experiences in the future [37] while the depression-related stigma measure ascertains perceptions of an external, fictionalized individual exhibiting depressive symptoms. In addition to this limitation, a single question in which respondents could select a single response was used to ascertain causal attribution as a form of depression-related stigma. This approach may have prevented us from adequately capturing the complexity of attribution beliefs in which individuals feel there are multiple causes of distress. Future studies should use well-validated, comprehensive measures to assess both HIV- and depression-related stigma and aim to assess the relationship between similar forms of stigma (e.g., internalized or enacted HIV- and depression-related stigma) to understand the extent to which relationships vary across stigma types. As mentioned above, this study captured HIV- and depression-related stigma at HIV care initiation. HIV- and depression-related stigma and how they intersect to influence physical and mental health outcomes may change as an individual is established on treatment for HIV, seeks routine care, and develops more robust and trusted support systems within and external to the health care system. As such, longitudinal data on these types of stigmas are needed. Additionally, this study included individuals who were both newly diagnosed with HIV and those known to be living with HIV who may have previously been in care. We did not have data regarding the timing of diagnosis with HIV and were unable to capture differences, particularly in endorsement of HIV-related stigma, that may have arisen between those who were newly diagnosed and those known to be living with HIV. Finally, participants were recruited from three urban healthcare facilities in Cameroon, limiting the overall generalizability of study findings.
Conclusions
HIV- and depression-related stigma are common among PWH entering HIV care in Cameroon. HIV-related stigma may be particularly detrimental to the mental well-being of PWH newly entering HIV care, necessitating urgent scale-up and incorporation of evidence-based HIV-related stigma interventions into existing linkage to care services.
Supplementary Material
Funding
This research was supported by NIMH grant K01 MH114721, NICHD grant P2C HD050924 (Carolina Population Center), NIAID grant U01AI096299, and NIMHD grant T37 MD014218. This work is solely the responsibility of the authors and does not necessarily represent the official views of any of the institutions mentioned above.
Footnotes
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s10461-024-04375-2.
Code Availability Code is available upon request from author LMF.
Ethical Approval This study was approved by the Institutional Review Board at the University of North Carolina at Chapel Hill and the National Ethical Committee of Research for Human Health in Cameroon.
Consent to Participate All participants provided written informed consent before the commencement of any study activities.
Conflict of Interest The authors declare no conflicts of interest.
Data Availability
Data may be available upon request from author AP.
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Data Availability Statement
Data may be available upon request from author AP.