Discrimination and Mental Health among Black and Latino People Living with HIV: Understanding the Role of Religion and Spirituality

Abstract

Despite significant advances in HIV care and treatment, Black and Latino people living with HIV (PWH) still face substantial health disparities due to discrimination and systemic inequities, which adversely affect their mental health. Given the profound significance of religion and spirituality in Black and Latino communities, the effects of religiosity on the relationship between discrimination and mental health should be examined. This study examined religiosity as a moderator between discrimination and mental health among Black and Latino PWH. Using data from the All of Us Research Program collected from 2016-2022, we analyzed electronic health records and survey responses from 902 participants, employing descriptive statistics, Chi-squared test, principal component analysis, and binary logistic regression. Results showed significant associations between education, employment, income, discrimination, religiosity, and mental health. Compared with no or low religiosity, those with high religiosity had significant higher odds of good mental health (aOR:2.35, 95% CI:1.16-4.75). Those who experienced discrimination had 59% lower odds of good mental health compared to those who did not report experiences of discrimination (aOR:0.41, 95% CI:0.20-0.83). There was no significant interaction effect of religiosity on the relationship between discrimination and mental health. While religiosity positively influences mental health, it does not mitigate the detrimental effects of compounded discrimination that Black and Latino PWH face. Continued collaborations between religious and spiritual leaders, researchers, and community members is needed to understand better the relationship between these factors and to identify strategies to maximize the protective effect of religiosity.

Introduction

Past decades were witness to remarkable advances in human immunodeficiency virus (HIV) related healthcare, and the current reality of living with HIV is similar to living with other chronic diseases [1]. By engaging in HIV care and adhering by their treatment plan, people living with HIV (PWH) can live long and healthy lives comparable to people without HIV infection [2]. Despite these life-changing advances, health inequities persist, resulting in wide variabilities in HIV transmission and related health outcomes [3]. According to the Centers for Disease Control and Prevention (CDC), Non-Hispanic Black/African American (hereafter referred to as Black) and Hispanic/Latino (hereafter referred to as Latino) remain disproportionately impacted by HIV, accounting for 69% of estimated HIV infections in 2021 [4]. Though HIV incidence rates have declined among these groups in past years, inequities persist due to systemic or otherwise discriminatory experiences of these communities [5]. Socially marginalized groups experience greater health burdens and worse outcomes due to a number of adverse factors [6]. These adverse factors can include systemic, and inter- and intra-personal experiences of disenfranchisement, and have negatively affected every domain of one’s life including mental and physical health, social standing, and overall quality of life of PWH [7, 8].

Intersectionality and Minority Stress Theory

People occupy multiple identities that might lead to multiform experiences of discrimination and disenfranchisement. Intersectionality, a concept grounded in Black feminism and Critical Race Theory, suggests that multiple forms of oppression and structural inequalities operate within interconnected systems of power [9, 10]. These systems reinforce unequal power dynamics among and between people, and social institutions such as healthcare and the legal system [9, 10]. The importance of intersectionality in HIV-related health and wellbeing outcomes cannot be overstated. Apart from experiences of discrimination within the context of race or ethnicity, Black and Latino PWH may also experience discrimination linked to their other identities, including living with HIV and/or being a sexual or gender identity minority [11]. It is also possible for discrimination to target specific intersections, such as discrimination attributed to being gay and Black [12]. Additionally, PWH who are at the intersection of multiple marginalized identities may experience discrimination both from inter- and intra-group members which further suggests a narrowing of potential safe spaces [13]. Minority Stress Theory postulates that intersecting identities create unique and compounded stressors that intensify the overall impact of discrimination on health and well-being, providing a framework to explain how these intersecting identities contribute to unique stressors, intensifying the effect of discrimination on the health of Black and Latino PWH. Within this framework, coping strategies and social support may help to mitigate the adverse effects of minority stress through resilience and community connection [14].

Discrimination and Mental Health among Black and Latino PWH

Extant literature consistently highlights the disproportionate psychosocial burdens on Black and Latino PWH in the United States [15, 16]. Several studies have shown that discrimination leads to poor mental health outcomes [17-19]. Researchers have consistently demonstrated that individuals who experience discrimination are more likely to suffer from depression, anxiety, suicide ideation, and other mental health issues [18, 20-22]. Discrimination can lead to poor mental health outcomes through various pathways, such as internalized stigma and shame, social isolation, and reduced access to services and support systems [17, 23, 24]. The adverse effects on mental health as a result of discrimination are widespread and affect various marginalized groups, including those discriminated against based on race, gender, sexual identity, and HIV status [17, 25-27]. Discrimination can occur across multiple levels (e.g., individual, community, structural) further exacerbating mental health issues within these groups [17]. Among Black and Latino people, especially those living with HIV, this issue is particularly significant, compounded by discrimination stemming from intersecting identities [28].

Though both Black and Latino people experience discrimination due to racial and ethnic bias in the United States, these experiences may present in unique yet overlapping ways. For instance, Black people are more likely to experience discrimination related to their skin color and anti-black racism, resulting in racial inequities in the criminal justice system, healthcare system, housing, educational system, and workforce [29-31]. Similarly, Latinos often face discrimination related to immigration status, language, and perceived nationality, many times resulting in barriers to accessing healthcare and services and fair treatment through the judicial system and workplace [32, 33]. Moreover, because of anti-Black racism, Afro-Latinos face colorism in Latino communities, compounding their experiences of racism [33, 34]. Despite the differences in these forms of discrimination, the resulting inequities affect all aspects of their lives.

Religion and Spirituality

Religion and/or spirituality (R/S) are intrapersonal practices that have been linked to coping, especially within the context of stigma and discrimination [35, 36]. Minority stress theory suggests that R/S may act as a coping mechanism and source of social support, possibly mitigating the adverse effects of discrimination on mental health [14]. Further, these factors have remained relatively under-explored within the context of HIV which points to a shortcoming in the literature as R/S have the potential to be utilized as culturally acceptable and sustainable interventions [37]. Considering the high levels of spirituality and religious affiliation amongst Black and Hispanic communities, these practices can potentially help mitigate the negative impacts of multi-form discrimination on mental health [38].

However, R/S is not a one-size-fits-all tool, and studies present mixed findings regarding its influence on HIV outcomes [39, 40]. While most included studies support the positive impact of R/S on HIV related health outcomes such as medication adherence, viral suppression, and care retention, others find no such support or underscore the potential negative impacts of R/S [39-45]. For instance, Dalmida et al. (2023) found that PWH who prayed at least once daily were 2.26 times more likely to adhere to ART medications ≥90% of the time compared to those who prayed less than daily [42]. Similarly, Van Wagoner et al. (2018) found church attendance to be significantly associated with reduced odds of viremia (AOR 0.5; 95% CI 0.2, 0.9) among a sample of PWH in the Southeastern US [45]. Moreover, R/S has been linked to improvements in mental health and health related quality of life (HRQoL) among PWH [46, 47]. One study demonstrated that patients who identified as traditionally religious (highest overall religiousness/spirituality) reported significantly higher mental health and HRQoL, and health improvement over the last four weeks compared to other groups (i.e., privately religious, spiritual but not religious) among a predominantly Black sample of PWH [47].

On the other hand, some studies have highlighted the potential disadvantages of R/S on HIV-related health outcomes [35, 48-50]. For example, Zainel-Abiden et al. (2024) found that PWH who adopted religion/spirituality coping mechanisms were less likely to be adherent to ART [48]. Another study reported that superstitious beliefs about HIV, faith healers, and pastors in the media space who claim to cure HIV hinder HIV treatment and care by causing confusion and spreading misinformation and disinformation [49]. These mixed findings suggest that the impact of R/S, as with any other protective factor, is contextual and cannot be expected to be as effective amongst all. However, the findings suggest that there might be several benefits that are worthy of further empirical attention.

Beyond its direct effects, R/S may have an indirect effect on HIV-related health outcomes [51, 52]. For example, researchers found a 1-SD increase in spirituality/religion was associated with a 68.50% increase in the odds of feeling that life has improved, with 29.97% of this effect being direct and 38.54% having occurred through mediated pathways such as health beliefs and health status/concerns [52]. Another study demonstrated that stress-related growth mediates the relationship between spirituality and psychological adjustment (e.g., happiness and sadness) among Indians living with HIV [51]. These findings highlight the complexity of R/S concerning HIV-related outcomes.

Further, R/S has been found to act as a moderator, with researchers demonstrating that religious coping significantly moderates the relationship between gendered microaggressions and adherence and viral load suppression among Black women living with HIV [53]. Another study found that religiosity moderated the relationship between HIV-related stigma and depression [54].

Poor mental health among PWH leads to suboptimal HIV care outcomes, including delayed linkage to care, inadequate adherence to antiretroviral therapy, and challenges in achieving viral suppression [55, 56]. Strategies to improve the mental health and well-being of Black and Latino PWH should prioritize the social experiences of these marginalized communities, highlighting the need to reduce the burden of discrimination among PWH, particularly racial and ethnic minorities. Given that more than 97% and 85% of Black and Latino individuals, respectively, report believing in God or a higher power, R/S may serve as an important factor or strategy to buffer against discrimination among these groups [57, 58]. Therefore, our study aims to examine religiosity as a moderator of the relationship between discrimination and mental health among Black and Latino PWH. Based on existing literature suggesting the protective role of religiosity on mental health outcomes, we hypothesize that higher levels of religiosity will buffer the negative impact of discrimination on mental health. This study is one of few to examine religiosity as a moderator of the relationship between intersectional discrimination and mental health among Black and Latino PWH.

Methods

Setting and Study Design

We conducted a retrospective cohort study using All of Us Research Program (AoU) data. The AoU, administered by the National Institutes of Health (NIH), launched in May 2018 and aims to enroll at least one million individuals 18 years and older, particularly from underrepresented groups [59]. The recruitment methods and scientific rationale for AoU have been described elsewhere [59]. AoU uses a variety of data collection sources, including questionnaires, electronic health records, and biometric measurements. Participants gave informed consent to share their data with the research team. The AoU Research Program received approval from the NIH Institutional Review Board.

For this study, we included participants enrolled in 2018 who had available electronic health record data and completed the AoU Social Determinants of Health survey. Although enrollment occurred in 2018, electronic health records and survey data were available for all participants from 2016 to 2022. Participants were included in the cohort if they met the following criteria: 1) aged 18 years or older, 2) identified as Black or Latino, and 3) had confirmed HIV-positive status. HIV status was confirmed using AoU electronic health records. Participants with missing data on mental health, discrimination, and religiosity were not included in the study. The total number of participants who met the minimum eligibility criteria (i.e., Black or Latino, HIV positive, etc.) was 8,049. After accounting for the missing values, the sample size for this study was 902. This sample size was sufficient for carrying out the planned analysis.

Measures

Socio-demographics

Sociodemographic variables included age, race/ethnicity, gender, sexual identity, education, employment, health insurance coverage, income, and nativity. Age was calculated based on the participant’s birthdate and the date of the survey. Race/ethnicity categories included “Non-Hispanic Black/” and “Latino.” Nativity categories included “US-born” and “foreign-born.” Gender identity was categorized as “man,” “woman,” or "transgender or gender diverse." Sexual identity categories included “heterosexual” and "gay/lesbian,", "bisexual, or "another sexual identity." Education was categorized as “less than a high school degree,” high school diploma or GED”, “college degree”, “college graduate or above,” and “other.” Employment categories included “employed or self-employed,” “unemployed,” and “other.”

Mental Health

Mental health status was assessed using a self-reported measure from the AoU Overall Health survey. Participants were asked to answer the following question from the AoU Overall Health survey: “In general how would you rate your mental health, including your mood and your ability to think?” Responses ranged on a 5-point Likert Scale ranging from “excellent”, “very good”, “good”, “fair” to “poor”.

Discrimination

Discrimination experiences were ascertained using nine items from the Everyday Discrimination Scale (Cronbach’s alpha = .88) [60]. Example items include, “You are treated with less courtesy than other people are,” “People act if they are afraid of you,” and “You are called names or insulted.” Participants who indicated that they experienced discrimination a few times a year or more frequently were asked to indicate the reason for this experience. Specifically, participants were asked, “What do you think is the main reason for these experiences?” (e.g., race, age, religion). Responses ranged on a 5-point Likert Scale ranging from 1 = Almost every day to 6 = Never.

Religiosity

Religiosity was assessed using six items from the Brief Multidimensional Measure of Religiousness/Spirituality scale (BMMRS) (Cronbach’s alpha = .91) [61]. Sample items from the BMMRS include “I feel God’s (or a higher power’s) presence,” “I feel deep inner peace or harmony,” and I desire to be closer to or in union with God (or a higher power). Responses ranged on a 7-point Likert scale from 1 = Many times a day to 6 = Never or almost never. Four items also included responses indicating unbelief or being nonreligious, such as: “I am not religious” or “I do not believe in God (or a higher power).” The widely used BMMRS captures diverse elements of religiousness/spirituality, including spiritual dimensions (i.e., daily spiritual experiences, beliefs, meaning, forgiveness, values), private rituals (e.g., prayer), organized practices (e.g., service attendance), and religiously-based social support [61, 62]. The BMMRS has been used with persons of diverse medical conditions, including PWH, and those of diverse cultural backgrounds [63-65].

Statistical Analysis

Demographics, religiosity, and discrimination experience were summarized using descriptive statistics (e.g., Mean ± S.D.) as appropriate for continuous variables and frequency and percentage for categorical variables. Data quality was checked, including steps like outlier detection [66]. The outcome variable, mental health, was recategorized into a binary outcome: good mental health (including excellent, very good, or good) and poor mental health (including fair or poor). The association between individual socio-demographics, religiosity, and discrimination experiences with mental health was assessed using the Chi-squared test. A significance level of p<0.05 was set as a threshold.

Principal component analysis (PCA) of the six religiosity survey items and nine discrimination survey items was conducted using Kaiser’s criterion for factor extraction [67]. Components with an eigenvalue ≥ 1.0 were extracted. Only one component was extracted for both religiosity and discrimination thus no rotation was necessary. The extracted religiosity and discrimination principal component factors were recategorized into binary variables for each component based on the component mean values of 0 (with principal components standardized to a mean of 0 and a standard deviation of 1) positive component score for religiosity was defined as having strong religious beliefs, while a negative component score indicated weaker or no religious beliefs. Similarly, a positive component score for discrimination signified experiencing discrimination, whereas a negative component score indicated no experience of discrimination [67].

PCA was chosen as the analytical method due to the highly correlated nature of the six religiosity items and nine discrimination items. PCA is an effective method for reducing dimensionality and creating a composite measure when multiple variables are highly correlated (Supplementary Table 1). In this study, PCA allows us to extract a single component for both religiosity and discrimination, representing the overall construct for each. Given that only one component was extracted for each construct, no rotation was necessary. Generalized binary logistic regression was used to assess the impact of discrimination and religiosity on mental health, with the ability to control socio-demographic factors. This combination of PCA and logistic regression provides a robust framework for exploring the relationships between these variables and their influence on mental health outcomes. Furthermore, unlike CFA and SEM, which focus on testing latent constructs, PCA is appropriate for this study as we aim to explore R/S as a composite measure rather than validating a predefined factor structure. Previous studies have used similar methods to construct composite religiosity and discrimination measures [62, 68-70].

A generalized binary logistic regression was employed to examine the effects of discrimination and religiosity on mental health and to determine whether religiosity moderates the relationship between discrimination and mental health by controlling for individual-level socio-demographics. The regression model was constructed by (1) analyzing the impact of discrimination on mental health, considering socio-demographics, and (2) assessing the effect of religiosity as a protective factor against discrimination while controlling for socio-demographic factors as confounders. To test the moderating effect of discrimination and religiosity in logistic regression, an interaction term between discrimination and religiosity (discrimination attribution and religiosity) was added to the regression model. Adjusted odds ratios with 95% confidence intervals were generated for socio-demographic variables, religiosity, and discrimination. All analyses were conducted within the secure informatic AoU workspace using R 4.3 (R Foundation for Statistical Computing) and Python 3.12 (Python Software Foundation).

Results

Socio-demographic characteristics of the sample of Black and Latino PWH (n=902) are shown in Table 1. The average age of the participants was approximately 54.7 years (SD=12.7 years). More than half of the participants were women (n=528, 58.5%), identified as heterosexual (n=699, 77.5%), held a college degree or higher (n=555, 62.5%), with annual income less than $50,000 (n=628, 77.1%) and unemployed (n=499, 57.0%). Out of 902 participants, 75.5% (n=681) reported good mental health. More than 40% of participants reported having experienced discrimination (n=381, 42.2%). Among participants who reported experiences of discrimination a few times a year or more frequently (n=302), more than 10% attributed their discrimination experiences to race (17.3%) or ancestry or national origins (10.6%). Additionally, the majority of participants reported strong religious beliefs versus no or low religiosity (n=533, 59.1% versus n=369, 40.9%). (Table 1). Among Black PWH, 66.5% (n=338) reported strong religious beliefs compared with 52% (n=205) of Latino PWH who reported strong religious beliefs (χ² = 19.49, p<.001). Among Black PWH, 48.8% (n=248) reported having experienced discrimination compared to 33.8% (n=133) of Latino PWH (χ² = 20.63, p<.001). The majority of both Black (n=380, 74.8%) and Latino (n=301, 76.4%) PWH reported good mental health, with no significant difference in mental health status found between the two groups.

Table 1.

Basic Socio-demographic Characteristics of Black and Latino People Living with HIV (N=902)

Socio-demographic Characteristics	Total (N=902)
Age (Mean, SD)	54.7 (12.7)
Age
18-44	205 (22.7)
45-64	488 (54.1)
≥65	209 (23.2)
Gender Identity, N (%)
Man	354 (39.2)
Woman	528 (58.5)
Transgender or gender diverse1	20 (2.2)
Sexual Identity, N (%)
Heterosexual	699 (77.5)
Gay/Lesbian	121 (13.4)
Bisexual	42 (4.7)
Another sexual identity	40 (4.4)
Race & Ethnicity, N (%)
Black	508 (56.3)
Latino	394 (43.7)
Education, N (%)
Less than high school degree	138 (15.5)
High school or GED	195 (22.0)
College degree	286 (32.2)
College graduate or above	269 (30.3)
Employment, N (%)
Employed or self employed	377 (43.0)
Not currently employed for wages	499 (57.0)
Health Insurance Covered, N (%)
Yes	821 (93.6)
No	56 (6.4)
Income
Less than 50,000	628 (77.1)
50,001-100,000	115 (14.1)
> 100,000	71 (8.8)
Birthplace, N (%)
US-born	626 (69.4)
Foreign-born	276 (30.6)
Religiosity
High	533 (59.1)
No or low	369 (40.9)
Discrimination
Yes	381 (42.2)
No	521 (57.8)
Mental Health Status
Good	681 (75.5)
Poor	221 (24.5)

Abbreviations: SD, standard deviation; GED, graduate equivalency degree diploma after graduating from high school.

¹Transgender or gender diverse options include non-binary, transgender, gender diverse, prefer not to answer, or skipped.

The frequency may vary slightly due to non-response/missing values

The binary logistic regression results in Table 2 indicated that religiosity had a significant positive influence on mental health among Black and Latino PWH (OR: 2.35, 95% CI: 1.16-4.75). Specifically, compared with no or low religiosity, those with high religiosity have 2.4 times higher odds of good mental health. Moreover, discrimination has a significant negative influence on mental health among Black and Latino PWH (OR: 0.41, 95% CI: 0.20-0.83). More specifically, compared with those who reported no experiences of discrimination, those who reported experiences of discrimination had 59% lower odds of having good mental health. There was no significant interaction effect of religiosity on the relationship between mental health and discrimination, indicating that religiosity does not buffer the impact of discrimination on mental health.

Table 2.

Impact of Discrimination and Religiosity on Mental Health, Controlled by Socio-demographic Factors

Parameter1	Adjusted Odds Ratio (aOR)	95% C.I.
		Lower	Upper
Discrimination
Yes	.409**	.202	.829
No	1	.	.
Religiosity
High	2.348*	1.161	4.752
No or Low	1

Abbreviations: aOR, adjusted odds ratio; C.I., confidence interval; SD, standard deviation; GED, graduate equivalency degree diploma after graduating from high school.

¹Model 1: analyzing the impact of discrimination on mental health among Black and Latino PWH, controlling for age, gender, sexual identity, education, employment, income, insurance, and nativity.

^*p value < 0.05,

^**p value < 0.01

Discussion

This study is among the few that examine the role of religiosity in moderating the effect of intersectional discrimination on the mental health of Black and Latino PWH. By exploring how R/S might influence or buffer the adverse effects of discrimination based on race, ethnicity, and HIV status, we shed light on potential protective factors that can improve the mental health of these communities, particularly those most vulnerable to HIV infection. Though religiosity was found to have a protective effect on mental health in this study, there was no evidence that supports the hypothesis that religiosity protects against the effects of discrimination among Black and Latino PWH. This finding may be explained in a variety of ways.

For Black and Latino people, discrimination does not occur in isolation but rather intersects, creating compounded stressors that are more intense and frequent [17, 28]. The intersectionality of marginalized identities such as race, ethnicity, HIV status, gender, and sexual identity may intensify the discrimination experienced, making it more severe and leading to adverse mental health outcomes, including increased depression, anxiety, and stress [26, 71-74]. Experiences of discrimination within religious and spiritual communities may mirror or exacerbate the broader societal biases [75]. While religiosity has the potential to offer support, its role is dependent on the inclusivity of the religious and spiritual communities. Some religious communities may perpetuate stigma, shame, or guilt associated with HIV or other marginalized identities, including racial/ethnic minorities and sexual gender minorities [38]. Moreover, religious/spiritual beliefs and teachings on sexuality may conflict with the identities of many PWH, leading to exclusion and distancing of PWH within religious and spiritual communities causing psychological distress rather than alleviating it [40].

For instance, findings from a recent systematic review on the impact of adverse religious experiences on the mental health of LGBTQ+ found the majority of LGBTQ+ individuals have encountered negative religious experiences, such as microaggressions and abuse within the religious setting, rejection due to their sexual identity, the conflict between their religious identity and sexual identity, and extent of rejection of religious practice throughout their lifetime [76]. Findings from this review underscore how negative discriminatory experiences within religious communities, have significant mental health effects, including increased rates of depression, anxiety, internalized stigma, and substance abuse [76]. Because of this, Black and Latino individuals living with HIV may not have access to religious communities that offer the social support and affirmation to protect against discrimination-related stressors effectively [75]. Thus, future research should consider the specific processes through which negative discriminatory experiences within religious communities lead to poor mental health outcomes and examine the support systems within religious communities that might protect against the negative effects of discrimination. Additionally, future research should explore identity conflicts between religious identities, HIV positive status, and other identified marginalized identities (e.g., race/ethnicity, sexual, and gender identities) to better understand the complex interactions between these identities and how they contribute to unique experiences of discrimination and poor mental health.

Furthermore, Black and Latino people are not monolithic communities. Both groups encompass diverse customs, traditions, and historical backgrounds, contributing to their unique and varied experiences [77]. These communities also include individuals with different sexual and gender identities, further enhancing their diversity. Thus, religiousness and spirituality may have different meanings and manifestations within Black and Latino communities depending on their religious and cultural contexts [38]. Spiritual and religious support needs may also differ among individuals [38]. For instance, religion and spirituality can consist of intrapersonal practices (i.e., prayer or dialogue with a higher power), interpersonal practices (i.e., dyadic practices of religion, bible study with a partner), or collectivist practices (i.e., wherein an individual is affiliated with a religious institution or attends church) [78]. Furthermore, the role of spiritual leaders and interpretation of religious texts can differ significantly [38]. This complexity has led to conceptual disarray amongst researchers and leads to limited findings in the area as measures used in religiosity studies can assess differing forms of connectedness [43]. We must consider the complexity of religious and spiritual practices; as there are multiple forms of connecting with a higher power [79]. Assessing religiosity without taking into consideration these context-specific aspects may lead to an incomplete understanding of how religiousness and spirituality impact one’s mental health. Therefore, future research should explore the complexities of religiosity within Black and Latino communities, particularly among PWH, taking into consideration aspects such as specific denominations, teachings on sexuality, and support needs. This is crucial for understanding how religiosity affects mental health among these groups, and a more nuanced approach is needed to capture these differences fully.

This study’s strengths include a large sample size, using electronic health record data, and advancing the existing HIV literature. Additionally, the use of BMMRS is a strength of this study as it captures both R/S, unlike other widely used measures that are limited to specific aspects of religiousness or spirituality, such as the Duke University Religion Index (DUREL), The Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Expanded (FACIT-SpEx), and Brief RCOPE [80].

These findings should be considered in the context of several limitations. First, we used cross-sectional survey data, which limits the ability to interpret findings as evidence of causal relationships. Additionally, AoU is not a representative sample of the U.S. population; therefore, findings from this study may not be applicable to the general population. Moreover, Black and Latino individuals are not a monolithic group; their lived experiences regarding discrimination and religiosity can vary widely, particularly concerning nativity [81-84]. Future research should account for regional differences and nativity to capture these differences and unique experiences fully.

Another limitation concerns our methodological approach. While the use of PCA and the BMMRS is appropriate for our study, it may have introduced some limitations. PCA does not measure underlying or latent constructs but rather groups items based on shared variance, potentially combining multiple dimensions of R/S. In contrast, other analysis techniques, such as CFA or SEM, can do this [47, 80]. Additionally, while the BMMRS captures multiple dimensions of R/S, our adapted version of this measure did not fully capture the complexity or interrelatedness of specific dimensions, such as meaning/peace, tangible connection to the divine, positive religious coping, over/appreciation, religious coping or culturally specific aspects of R/S, particularly within this racial and ethnic minority sample with HIV infection as prior research has demonstrated [47, 80].

Further complicating this issue, this study assumes a single continuum of religiosity. However, prior research suggests that this population may not be homogeneous concerning R/S [47]. Future research should employ alternative analytical approaches, such as CFA, SEM, or LCA, to explore subgroups of R/S among racial and ethnic minorities living with HIV and further validate its multidimensional structure of R/S concerning discrimination and mental health. Despite these limitations, our study corroborates existing BMMRS literature, demonstrating that R/S protects against poor mental health [46, 47, 51, 52].

While religiosity positively influences mental health, it does not mitigate the detrimental effects of compounded discrimination that Black and Latino PWH face. Though religious and spiritual communities can offer support, this is often hindered by existing stigmas and exclusions within these groups. Collaborative efforts between religious and spiritual leaders, researchers, and community members have been carried out among diverse populations to reduce stigma and discrimination at the broader societal level [85-88]. This continued collaboration will enable an in-depth understanding of the diverse religious and spiritual expressions and the impacts of these multidimensional concepts on mental health, leading to the development of effective culturally relevant interventions. Ultimately, resulting in more inclusive and supportive religious and spiritual communities for Black and Latino PWH not only to demonstrate resilience but more importantly thrive, finding strength, connection, and purpose within their religious and spiritual beliefs.