Moment-to-moment within-person associations between acts of discrimination and internalized stigma in people living with HIV: An experience sampling study

Abstract

Internalized stigma related to HIV is associated with poorer outcomes for people living with HIV (PLWH). However, little is known about the association between experiences of daily acts of discrimination by others and the activation of internalized stigma, including factors that may moderate this association. One hundred nine men living with HIV responded to experience sampling method (ESM) questions 3 times a day for 7 days via smart-phones. ESM questions included experiences of recent acts of discrimination, internalized HIV stigma, avoidance coping with HIV, and recent social support. We also administered several traditional questionnaire measures assessing psychosocial constructs. In Hierarchical Linear Modeling analyses controlling for age, race, socioeconomic status, and time on antiretroviral therapy, experiencing discrimination predicted internalized stigma within-persons. Individuals higher on attachment-related avoidance, attachment-related anxiety, avoidance coping, perceived community stigma, and helplessness, and individuals lower on social support, had stronger associations between discrimination and current internalized stigma. Similarly, results from two state moderator variables supported our trait analyses: State-level (ESM) social support and avoidance coping were significant moderators. Thus, when PLWH experience incidents of discrimination due to HIV, this may lead to increased feelings of internalized stigma. We extend the literature by demonstrating that the associations between experienced and internalized stigma are not just at the generalized trait level, but also occur at the state-level, accounting for within person variability. Results provide implications for interventions aiming to modify maladaptive interpersonal traits as well as interventions to increase social support to reduce the impact of discrimination on PLWH.

INTRODUCTION

Despite advances in HIV treatment and increases in life expectancy, the social context of living with HIV, including experiences with HIV-related stigma, still pose a threat to the health and well-being of people living with HIV (PLWH). Research suggests that HIV-related stigma can lead to poorer outcomes such as HIV-related symptoms, poor medication and visit adherence (Helms et al., in press; Turan, Smith, et al., 2016; Vanable, Carey, Blair, & Littlewood, 2006), depression (Mitzel et al., 2015; Rao et al., 2012; Turan, Smith, et al., 2016), and risky sexual behaviors (including failure to disclose HIV status to partners) (Turan & Nyblade, 2013). This association between stigma and poor health outcomes is not unique to HIV, and has also been observed in other stigmatized conditions (Cox, Abramson, Devine, & Hollon, 2012). While stigma and prejudice are experienced in other medical conditions (e.g., schizophrenia) (Corrigan, 2004), HIV in particular is a highly stigmatized disease historically, due to its association with certain behaviors, and also given that many of the populations highly affected by the HIV epidemic are also marginalized and outcast by society regardless of HIV status, leading to intersectional stigma. These populations include men who have sex with men, intravenous drug users, individuals of low socioeconomic status (SES), minority groups (particularly African Americans in the rural south), and older adults (Emlet, 2006; Herek, 2002). Although HIV is usually a concealable stigmatized identity, that may not be readily apparent, it nonetheless may result in experiences of stigma that may be influenced/activated by both intentional and non-intentional disclosure, experiences of discrimination, and common assumptions and attitudes about PLWH (Quinn & Earnshaw, 2013). Thus, stigma is inherently a social (i.e., interpersonal as opposed to intrapersonal) process (or at least initiates as such) (Earnshaw & Chaudoir, 2009; Link & Phelan, 2006; Sayles et al., 2008). According to modern conceptualizations of stigma, the process of stigma begins with a social selection process in which the society identifies and labels human differences, and those attributes that are deemed undesirable/socially devalued are then stigmatized and linked to a person with the undesirable attribute (e.g., stereotyping) (Link & Phelan, 2006).

There are several theoretical models for the mechanisms underlying the association between social stigma and individual outcomes in PLWH, which are rooted in Goffman’s (1963) classic theory of stigma. The HIV Stigma Framework by Earnshaw and Chaudoir (2009) posits that PLWH experience stigma through distinct stigma mechanisms (also see Turan, Budhwani et al., 2016), which in turn may lead to adverse physical and mental health outcomes. These mechanisms are enacted stigma, anticipated stigma, and internalized stigma (Earnshaw & Chaudoir, 2009; Earnshaw, Smith, Chaudoir, Amico, & Copenhaver, 2013). Enacted (or experienced) HIV stigma refers to the degree to which PLWH experience prejudice or acts of discrimination. Anticipated stigma refers to the degree that PLWH expect they will experience prejudice and discrimination in the future. Internalized HIV stigma refers to accepting and endorsing negative beliefs about PLWH as applying to the self, with ensuing feelings of shame and inferiority due to living with HIV (Earnshaw & Chaudoir, 2009; Earnshaw, Smith, et al., 2013). In this seminal work on the HIV Stigma Framework by Earnshaw and Chaudoir (2009), the authors highlight the importance of examining moderating factors that may make some individuals more susceptible to HIV stigma experiences than others, yet little research exists on this topic to date.

The association between discrimination and internalized stigma is particularly important, as the crucial contributing factor in the path from a negative external stimulus (i.e., discrimination) to resulting emotions and behaviors is the cognitive/affective component (i.e., internalized stigma), which is often automatic in nature (Cox et al., 2012). Thus, further understanding the profile of those PLWH most at risk for internalized stigma may be particularly important in predicting health outcomes (Turan, Smith, et al., 2016). The notion of internalization of stigma suggests that specific acts of discrimination by others may lead to increases in feelings of shame due to living with HIV, at least under certain circumstances (Cox et al., 2012; Earnshaw, Quinn, Kalichman, & Park, 2013; Earnshaw, Smith, et al., 2013). However, there may be individual differences in the extent to which a person gets affected by specific acts of discrimination by others and internalizes these interpersonal experiences (Hatzenbuehler, Nolen-Hoeksema, & Dovidio, 2009). That is, the process of internalization of external stigma (i.e., the transformation of interpersonal stigma to intrapersonal cognitions and affect) may be stronger for some PLWH compared to others as a function of psychosocial and interpersonal factors, such as maladaptive coping (i.e., blame coping and avoidance coping), insecure attachment styles, helplessness, and poor social support.

For example, individuals higher on the two dimensions of insecure attachment—attachment related anxiety (e.g., worry about relationships and over-reliance on partners) and attachment related avoidance (e.g., preference for over-independence and an avoidance of intimacy) might be more susceptible to internalizing experienced discrimination. Studies suggest that attachment theory is useful for explaining interpersonal as well as intrapersonal outcomes, as attachment styles can influence factors such as emotion regulation, stress reactions, and interpersonal functioning (Hunter & Maunder, 2001), including coping with a chronic disease (Ciechanowski, Sullivan, Jensen, Romano, & Summers, 2003) and social support seeking (Mikulincer & Florian, 1995). Recently, it has been reported that in PLWH the effect of internalized stigma on medication adherence is mediated by attachment related anxiety (Helms et al., in press). Similarly, it has been shown that avoidance coping with HIV, attachment related avoidance, perceived HIV stigma in the community, and helplessness cognitions moderate the association between social support and HIV treatment self efficacy, such that those with high levels of these maladaptive factors were more positively affected by social support (Turan, Fazeli, Raper, Mugavero, & Johnson, in press). It is possible that similar factors moderate the association between discrimination and internalized stigma, such that those with poorer functioning on specific psychosocial factors may be more at risk for experiencing internalized stigma when they face discrimination, whereas those without such poor functioning may be less affected or not affected at all by discrimination.

Furthermore, other studies in HIV have emphasized that identifying and enhancing resilience resources such as social support and adaptive coping are important for buffering the harmful effects of stigma (Earnshaw, Lang, Lippitt, Jin, & Chaudoir, 2015; Earnshaw, Bogart, Dovidio, & Williams, 2013). There is indeed evidence in the literature suggesting that factors such as hopelessness (Lee, Kochman, & Sikkema, 2002), maladaptive coping (Emlet, Brennan, et al., 2013), insecure attachment styles (Helms et al., in press; Riggs, Vosvick, & Stallings, 2007), and low social support (Emlet, Brennan, et al., 2013; Lee et al., 2002) are associated with greater internalized stigma in PLWH. Furthermore, perceived community stigma has been associated with internalization of stigma, and in fact internalized stigma may mediate the association between perceived community stigma and health outcomes (Turan, Budhwani et al., 2016). Thus, while all of these aforementioned constructs have been demonstrated to predict internalized stigma, it is plausible that these variables may also moderate the associations between discrimination and internalized stigma. However, no studies have examined the role of these variables in the internalization of stigma after an act of discrimination. Altogether, psychosocial interpersonal and intrapersonal functioning and resources are compromised in PLWH and may also be important factors affecting stigma processes in this population.

The precise mechanisms of how enacted stigma (experiencing acts of discrimination) leads to internalization of stigma and how internalized stigma affects individuals with HIV cannot be completely understood using conventional questionnaire measures. Stigma questionnaires require responders to take a mental average of their experiences over time, and compare them to other people’s experiences. That is, self-reports of global tendencies have the disadvantage of relying on responders’ ability and willingness to report how they generally perceive, feel, and think across situations. Conversely, emotions themselves are episodic occurrences specific to the moment in which they are experienced. Experience sampling method (ESM), a method widely used in psychological research, is an effective way to ask participants multiple times during daily life about their emotions and experiences while they are occurring. ESM assesses “state” levels of cognitions and emotions as they occur in the moment, whereas questionnaires assess general (trait) levels. ESM attempts to avoid inaccuracies and biases associated with global judgments (Nezlek, 2007; Trull & Ebner-Priemer, 2014) and may help us to obtain a fuller understanding of what PLWH experience daily due to living with a highly stigmatized condition.

Importantly, ESM also allows researchers to conduct within-person analyses that make it possible to examine relevant processes that co-occur for a given person. Within-person associations can have important theoretical and practical implications not revealed by between-person effects (Affleck, Zautra, Tennen, & Armeli, 1999; Nezlek, 2007). For example, ESM allows us to examine whether a participant’s feelings of internalized stigma are higher at times when that participant feels stigmatized or discriminated against by others. While the HIV stigma literature has focused on discrimination and internalized stigma, no studies have addressed the link between these two stigma mechanisms by examining moment-to-moment within-person associations using ESM, and examining potential risk and protective factors that might moderate the within-person association between discrimination and internalized stigma. ESM can examine whether the same individual may be less affected by discrimination at certain times compared to other times (e.g., when the person has just received social support related to HIV or when the person is not currently using avoidance as a strategy to cope with HIV). Identifying such moderating factors may be particularly important for the development of intervention strategies to reduce internalized stigma, when the objective of intervening upon discrimination in society may not be practical or immediately attainable.

Therefore, the aim of this study was to gain a more in depth understanding of day-to-day stigma experiences of PLWH by examining changes in internalized stigma for the same person across time. Specifically, we aimed to: 1) examine the within-person association between acts of discrimination and internalized stigma; 2) evaluate whether individuals higher on maladaptive psychosocial constructs such as attachment-related avoidance, attachment-related anxiety, avoidance coping with HIV, blame coping with HIV, helplessness, and perceived community stigma, and individuals with lower levels of social support have stronger associations between experiences of acts of discrimination due to having HIV and ensuing feelings of internalized stigma; and 3) examine whether individuals have stronger associations between acts of discrimination due to having HIV and internalized stigma at those instances when they try to avoid thinking about their HIV and when they are experiencing lower social support (i.e., within-person ESM moderators of the association between acts of discrimination and internalized stigma).

METHODS

Participants and Procedures

Participants were recruited from an HIV clinic at a research university in Birmingham, AL for a study on psychosocial aspects of living with HIV. Men living with HIV who were not current substance users and were on antiretroviral therapy (ART) were included (N = 109). Participants received smart phones provided by the study and subsequently responded to ESM questions three times daily for one week. Participants also completed questionnaires on demographic characteristics and psychosocial and interpersonal constructs during their in-person study visits. This protocol was approved by the Institutional Review Board of the University and all procedures were carried out with the understanding and written consent of the participants.

Experience Sampling Method (ESM)

Participants received alerts to respond to the same ESM questions three times a day for seven consecutive days. ESM times were preset by the researchers and spread out throughout the day. However, participants were told that ESM times were random. ESM questions included three items assessing experiences of actual discrimination by other people: (a) Since your last report, how much did you feel that someone treated you negatively because of your immune status? (b) Since last report, how much did you feel that someone kept their distance from you because of your immune status? (c) Since last report, how much did you feel that you were treated with less respect than other people because of your immune status? The term “immune status” was used instead of “HIV” for confidentiality purposes and this choice of wording was explained to the participants when they were given the smart phones and received instructions using them to respond to the experience sampling questions. Response choices ranged from 1 (not at all) to 5 (very strongly) and the mean of the three items at each sampling occasion was used to assess discrimination.

ESM questions also included two items assessing internalized stigma (i.e., “Since your last report, how ashamed did you feel about your immune status?” and “Since your last report, how much did you feel that you are not as good as other people because of your immune status?”). Response choices ranged from 1 (not at all) to 5 (very strongly) and the mean of the two items at each sampling occasion was used to assess internalized stigma. Another ESM item concerned recent acts of HIV-related social support (“Since last report, how much did someone give you support related to your immune status?). Response choices ranged from 1 (I received no support at all) to 5 (I received a huge amount of support). Finally, an ESM item measuring avoidance was used (i.e., “Since your last report, how hard did you try to avoid thinking about your immune status?” Response choices ranged from 1 (not at all) to 5 (extremely hard). On average, participants responded to 15.78 alerts (out of 21; SD = 4.79).

Questionnaire Measures

Attachment style

A shorter 18-item version of the most widely employed attachment style measure, Experiences in Close relationships (ECR, Brennan, Clark, & Shaver, 1998), was used. ECR assesses two dimensions of insecure attachment: anxiety (worry about relationships and over-reliance on partners) and avoidance (preference for over-independence and an avoidance of intimacy). An example from the anxiety scale is “I worry about being abandoned,” and an example of the avoidance scale is “I am nervous when partners get too close to me.” Participants rated each item on a 7-point likert scale ranging from 1 (strongly disagree) to 7 (strongly agree) and mean scores were used for both 9-item scales. Both anxiety and avoidance scales showed good internal consistency (Cronbach’s α = .88 and .90). Attachment-related anxiety and attachment-related avoidance were correlated (r = .61).

Coping with HIV

Two subscales from the revised Ways of Coping List (Vitaliano, Russo, Carr, Maiuro, & Becker, 1985) were used. The avoidance subscale includes 10 items (e.g., “I go on as if nothing had happened”) and the blaming self subscale includes three items (e.g., “I blame myself”). Participants were asked to use a 5-point likert scale from 1 (I don’t do this at all) to 5 (I do this a lot) to rate how much they use each strategy in response to experiences which remind them of having HIV. Mean scores were calculated for each subscale. Cronbach’s α was .77 for avoidance coping and .82 for blame coping.

Cognitions of helplessness due to HIV

The Illness Cognition Questionnaire for Chronic Diseases (Evers et al., 2001) was adapted to HIV as was done by Earnshaw et al. (Earnshaw, Smith, et al., 2013). This 18-item scale includes six items assessing helplessness (e.g., “My HIV controls my life”). Participants rated their agreement with these six helplessness items using a 4-point scale, and a mean score was calculated. Cronbach’s α was .81 in the current data.

Perceived HIV stigma in the community

Participants responded to a multidimensional HIV stigma scale developed by Berger et al. (2001) and revised by Bunn et al. (2007). This scale measures multiple dimensions of stigma associated with HIV. We focused on the 6-item subscale of concern with public attitudes (i.e., perceived stigma in the community; e.g., “Most people believe a person who has HIV/AIDS is dirty”). Participants rated each item from 1 (strongly agree) to 4 (strongly disagree). The mean of the items was used to assess the participant’s perceived HIV stigma in the community, with scores reversed so that higher scores reflect higher stigma. This subscale showed good internal consistency in the present study (Cronbach’s α = .87).

Social support

We used the 16-item Interpersonal Support Evaluation List-Short Form (Payne et al., 2012). A sample item is “When I need suggestions on how to deal with a personal problem, I know someone I can turn to”. Participants rated each item to indicate how true it is for them using a 4-point rating scale ranging from 1 (definitely false) to 4 (definitely true). Mean scores were calculated for this measure. Cronbach’s α was .88 in the current data.

Statistical Analysis

To examine the association between ESM acts of discrimination and ESM internalized stigma, Hierarchical Linear Modeling (HLM) (Raudenbush, Bryk, & Congdon, 2004) was used. Controlling for the covariates (age, race, SES, and time on ART), the within-person association between recent acts of discrimination and state internalized stigma was examined. Subsequent HLM analyses examined potential psychosocial and interpersonal moderators (both between-person and within-person state measures) of this association. First, we conducted a separate analysis for each between-person moderator —controlling for covariates, but not for the other moderators. A significant positive coefficient for the moderation effect indicates a stronger association between ESM acts of discrimination and ESM internalized stigma for individuals higher on the moderator variable. Then, we also built a model simultaneously entering all between-person moderators (age, race, SES, and time on ART were again entered as covariates). Note that in HLM analyses all level 1 variables were group-centered by subtracting the mean for a variable for all occasions for each participant from that participant’s scores and all Level 2 predictors were grand-centered by subtracting the mean for all participants from each participant’s score.

RESULTS

The sample included 50 white and 59 black participants with an average age of 41.36 (SD = 10.94), from different SES levels (with 54 reporting middle class SES). Descriptive statistics on the study variables are presented in Table 1. Preliminary analyses (comparing the variance of the error terms at Level 1 and Level 2) suggested that although the majority of the variance in momentary internalized stigma was between people (69%), there was considerable within-person variability in momentary internalized stigma (31%). In order to test the hypothesis that experiencing acts of discrimination due to having HIV explains part of this within-person variability in momentary feelings of ESM internalized stigma within persons, we conducted an HLM analysis using the following equations.

Table 1.

Descriptive statistics on the study variables

Variable	Mean (SD)	Range
Age	41.36 (10.94)	24–68
Time Since Starting ART Medication (Months)	79.29 (55.83)	12–227
ESM Questions
Internalized HIV Stigma	1.32 (0.3)	1.00–5.00
Discrimination Due to HIV	1.15 (0.61)	1.00–5.00
Social Support related to HIV	2.13 (1.54)	1.00–5.00
Avoidance Coping with HIV	1.44 (1.01)	1.00–5.00
Questionnaire Measures
Perceived HIV Stigma in the Community	2.65 (0.66)	1.00–4.00
Attachment-related Avoidance	2.95 (1.44)	1.00–6.33
Attachment-related Anxiety	3.48 (1.53)	1.00–7.00
Helplessness	1.76 (0.65)	1.00–3.50
Social Support	3.27 (0.55)	1.38–4.00
Blame Coping	2.24 (1.05)	1.00–5.00
Avoidance Coping	2.11 (0.71)	1.00–4.10

Note. ART = Antiretroviral therapy; ESM = Experience sampling method.

$$\begin{array}{ll}\underset{\_}{\text{Level}1:}\hfill & \text{ESM-internalized}{\text{stigma}}_{\text{ti}}={\mathrm{\beta }}_{0\mathrm{i}}+{\mathrm{\beta }}_{1\mathrm{i}}(\text{ESM-discrimination})+{\mathrm{e}}_{\text{ti}}\hfill \\ \underset{\_}{\text{Level}2:}\hfill & {\mathrm{\beta }}_{0\mathrm{i}}={\mathrm{\gamma }}_{00}+{\mathrm{\gamma }}_{01}(\text{age})+{\mathrm{\gamma }}_{02}(\text{race})+{\mathrm{\gamma }}_{03}(\text{SES})+{\mathrm{\gamma }}_{04}(\text{time}\text{on}\text{ART})+{\mathrm{u}}_{0\mathrm{i}}\hfill \\ \hfill & {\mathrm{\beta }}_{1\mathrm{i}}={\mathrm{\gamma }}_{10}+{\mathrm{\gamma }}_{11}(\text{age})+{\mathrm{\gamma }}_{12}(\text{race})+{\mathrm{\gamma }}_{13}(\text{SES})+{\mathrm{\gamma }}_{14}(\text{time}\text{on}\text{ART})+{\mathrm{u}}_{1\mathrm{i}}\hfill \end{array}$$

Level 1 is the within-person level examining the association between a person’s reported level of discrimination and the same person’s internalized stigma. Level 2 is the between-person level and the two Level 2 equations predict the slopes and the intercepts obtained from the Level 1 equations.

The results of the HLM analyses are presented in Table 2 and show that γ₁₀ was significant (coefficient = .128, t = 2.452, p = .016), indicating that on average acts of discrimination and internalized stigma were associated within-persons. This result suggests that when a person experiences specific incidents of discrimination due to his HIV status, this may lead to increased feelings of internalized stigma.¹ As shown in Table 2, the only predictor of the Level 1 association between discrimination and internalized stigma (β_1i) was age (γ₁₁), suggesting that this association is stronger for younger PLWH.

Table 2.

HLM results: Level 2 predictors of the Level 1 association (i.e., of slope β_1i) between discrimination and internalized stigma

Predictor	Estimate	t	p
Intercept (γ10)	0.128	2.452	.016
Age (γ11)	−0.008	−2.245	.027
Race (γ12)	−0.011	−0.140	.887
SES (γ13)	−0.019	−0.465	.642
Time on ART (γ14)	0.002	1.141	.257

We also tested potential psychosocial and trait moderators of this within-person association between acts of discrimination due to having HIV and current internalized stigma by adding potential moderators one by one (without controlling for other moderators) to both of the Level 2 equations. As can be seen in Table 3, attachment-related avoidance, attachment-related anxiety, avoidance coping with HIV, helplessness, perceived community stigma, and social support were significant moderators (i.e., significant predictors of β_1i). Individuals higher on attachment-related avoidance, attachment-related anxiety, avoidance coping with HIV, perceived community stigma, and helplessness had stronger associations between discrimination due to having HIV and current internalized stigma (all p-values < .01), whereas individuals higher on social support had weaker associations between discrimination due to having HIV and momentary internalized stigma (p = .002).

Table 3.

HLM results: Level 2 predictors (trait moderators when added one by one) of the Level 1 association (i.e., of slope β_1i) between discrimination and internalized stigma

Predictor	Estimate	t	p
Attachment-related avoidance	0.094	3.709	.001
Attachment-related anxiety	0.057	2.065	.041
Avoidance coping with HIV	0.212	8.394	.000
Blame coping with HIV	−0.002	−0.337	.736
Perceived community stigma	0.136	2.797	.007
Helplessness	0.217	9.529	.000
Social support	−0.183	−3.341	.002

Note. Age, race, SES, and time on ART were also entered as predictors in every model.

Follow-up simple slope analyses suggested that the Level 1 association between discrimination and internalized stigma was not significant at one standard deviation below the mean for avoidance coping (coefficient = −.005, t = −.07, p = .94), whereas at one standard deviation above the mean for avoidance coping, the Level 1 association between discrimination and internalized stigma was positive and significant (coefficient = .21, t = 5.21, p < .001). Similarly, the Level 1 association between discrimination and internalized stigma was not significant at one standard deviation below the mean for attachment-related avoidance, attachment-related anxiety, perceived community stigma, helplessness, or at one standard deviation above the mean for social support (coefficient = −.02, t = −.15, p = .88; coefficient = −.007, t = −.08, p = .94; coefficient = .04, t = .40, p = .69); coefficient = −.004, t = −.05, p = .96; coefficient = .02, t = .23, p = .82; respectively). On the other hand, at one standard deviation above the mean for attachment-related avoidance, attachment-related anxiety, perceived community stigma, helplessness, or at one standard deviation below the mean for social support, the Level 1 association between discrimination and internalized stigma was positive and significant (coefficient = .16, t = 3.41, p < .001; coefficient = .15, t = 3.68, p < .001; coefficient = .22, t = 2.95, p = .004; coefficient = .20, t = 5.00, p < .001; coefficient = 0.14, t = 3.21, p = .002; respectively). Blame coping with HIV was not a significant moderator (p = .736).

Next, we entered all moderators simultaneously into the Level 2 equation (age, race, SES, and time on ART were also entered as control variables). In this analysis, the following were significant moderators: avoidance coping (coefficient = .22, t = 3.14, p = .003), attachment-related avoidance (coefficient = .07, t = 3.05, p = .003), and blame coping (coefficient = −.10, t = −2.79, p = .007). It should be noted, however, that the moderator variables were highly correlated with each other, and multicollinearity may result in unreliable coefficients in regular regression analyses (Belsley, 1991) as well as in multi-level analyses (Kreft & De Leeuw, 1998).

We also tested the moderating effect of two state variables on the association between recent discrimination and internalized stigma. The Level 1 interaction between the level of support a participant received since the last sampling episode and level of experienced discrimination since the last sampling episode was a significant predictor of state internalized stigma (coefficient = −.110, t = −4.510, p < .001; the main effects of received social support and discrimination were also in the model). Follow-up analyses suggested that participants showed a significant positive within-person association between discrimination and internalized stigma at those times that they received low levels of support (coefficient = .657, t = 2.110, p = .037); this association was not significant when they received high levels of support (coefficient = .217, t = 1.664, p = .099).

Similarly, the Level 1 interaction between how hard participants tried to avoid thinking about their HIV since the last sampling episode and level of experienced discrimination since the last sampling episode was also a significant predictor of ESM internalized stigma (coefficient = .114, t = 5.220, p < .001). Follow-up analyses suggested that participants showed a stronger positive within-person association between discrimination and internalized stigma when they had tried hard to avoid thinking about their HIV (coefficient = .310, t = 6.932, p < .001) compared to when avoidance was low (coefficient = −.130, t = −.634, p = .527).

DISCUSSION

Given the demonstrated adverse effects of internalized HIV stigma on HIV-related outcomes, and the limited information on how stigma is internalized and processed, the aim of the current study was to shed light on the formation, maintenance, and activation of internalized stigma by examining the association between experiences of discrimination and internalized stigma in daily life of PLWH. We also examined whether individuals with specific dispositions (i.e., personality traits and psychosocial factors) or after certain experiences were more at risk to be negatively affected by discrimination, or conversely, whether certain factors may be protective against the effects of discrimination.

We found that stigma is a dynamic process and acts of discrimination against PLWH predicted internalized stigma within persons. This result suggests that when a person experiences specific incidents of discrimination due to his HIV status, this experience may lead to the activation of internalized stigma. This finding extends the current literature by demonstrating that the associations between these two stigma mechanisms are not just at the generalized trait level, but also occur at the state-level, and account for within person variability. This finding is also important because it demonstrates that while some PLWH may experience internalized stigma based on their own pre-existing notions and judgments about perceptions common in society (Cox et al., 2012), actual day to day acts of discrimination may activate, perpetuate, and reinforce internalized stigma.

We also found that several factors moderated the associations between discrimination and internalized stigma. First, the association between discrimination and internalized stigma was stronger for younger individuals, while no other demographic moderators were found. This moderating role of age could perhaps be due to greater hardiness/resilience and more frequent positive emotions in older people (Carstensen et al., 2011; Turan, Sims, Best, & Carstensen, in press). Hardiness and resilience are components of personal control, and refer to the ability to cope with negative stressors. Studies have suggested that older PLWH have higher levels of hardiness/resilience (Emlet, Tozay, & Raveis, 2011) (which may be associated with longer duration of the disease and/or higher levels of hardiness/resilience due to aging itself) and this is associated with higher levels successful aging (Moore et al., 2013). Thus it may be that older PLWH are less affected by discrimination than younger counterparts due to overall emotional maturity.

For our psychosocial measures, we identified several risk factors, such that individuals higher on attachment-related avoidance, attachment-related anxiety, avoidance coping with HIV, perceived community stigma, and helplessness had stronger positive associations between discrimination due to having HIV and current internalized stigma, while for those with low levels on these variables there was no association between discrimination and internalized stigma. In contrast, social support emerged as a protective factor, with individuals higher on availability of social support showing no association between discrimination due to having HIV and momentary internalized stigma, while those with lower availability of social support had significant positive associations between discrimination and internalized stigma. Blame coping with HIV was the only non-significant moderator. This may have been because this was the only moderator that has no interpersonal component, and was mostly intrapersonal, suggesting that interpersonal factors are more influential in internalizing discrimination. Further, it may be that if an individual has high self-blame (negative internal attributions), that person may be less affected by external blame (i.e., discrimination). Our examination of state (ESM) avoidance and social support also supported our psychosocial questionnaire moderators by showing that in general PLHW have greater within-person associations between acts of discrimination and internalized stigma at those times when they try to avoid thinking about HIV and have lower social support. The finding that both trait and state measures of social support and avoidance coping moderate the association between discrimination and internalization of stigma suggests that interventions targeting these moderating constructs have a good chance of being successful.

Altogether, our findings on moderators may be useful for both identifying those PLWH most at risk for internalization of stigma, as well as interventions that may be effective (particularly for those most at risk) in reducing the downstream effects of discrimination on internalized stigma in this population. Interventions such as cognitive behavioral therapy may aim to reduce maladaptive traits (e.g., avoidance coping, attachment-related anxiety) or promote social support directly with the goal of equipping individuals to be more resilient to discrimination and less prone to internalization of stigma. Alternatively, multilevel approaches can be used to targeting stigma directly in both those with and without stigmatizing conditions, at the intrapersonal, interpersonal, and structural levels (Cook et al., 2013).

While our results are consistent with the literature in other fields showing that specific traits moderate the association between rejection and outcomes (Ford & Collins, 2010), studies in PLWH to date have primarily focused on the direct association of these psychosocial factors with stigma (i.e., main effects). Indeed, the relationship that hopelessness (Lee et al., 2002), insecure attachment styles (Riggs, Vosvick, & Stallings, 2007), maladaptive coping (Emlet, Fredriksen-Goldsen, & Kim, 2013; Slater et al., 2015), and low social support (Emlet, Brennan, et al., 2013; Lee et al., 2002) have with greater internalized stigma in PLWH has been well-documented in the literature. However, the moderating role these maladaptive interpersonal traits play in the link between discrimination and internalized stigma, with the use of an intensive with-in person measurement technique (ESM), is a novelty of the current study. Our study extends these prior studies by showing that not only do these traits predict internalized stigma in PLWH, but they also increase the likelihood of acts of discrimination resulting in internalized stigma, such that acts of discrimination only predict internalization of stigma in those with maladaptive functioning on these variables. Furthermore, the protective role of social support on internalized stigma has been evidenced in the literature in PLWH (Emlet, Fredriksen-Goldsen, et al., 2013; Lee et al., 2002; Slater et al., 2015), and we now extend this literature by demonstrating that those with high levels of social support may be better able to prevent or buffer the effects of discrimination on internalized stigma.

ESM allows for this individual-level examination of internalized stigma in such a way that we can examine the association between acts of discrimination and internalized stigma as they happen (and thus when internalized stigma would be expected to be at its height). ESM has been used in other populations to examine stigma. For example, in schizophrenia ESM has been shown to be an effective method to examine the within-person impact of internal (e.g., mood) and external (e.g., social support) factors on stigma (Ben-Zeev, Frounfelker, Morris, & Corrigan, 2012). Similarly, using ESM in an African American cohort and a lesbian, gay and bisexual (LGB) cohort, Hatzenbuehler, Nolen-Hoeksema, and Dovidio (2009) found that emotion regulation strategy (i.e., rumination) was a mediator between stigma and psychosocial distress.

Despite the gaps in the literature addressed by this study, as well as the methodological strengths, this study is not without limitations. As this is a cross-sectional study, causation cannot be ascertained even though results of our trait, state, and (importantly) moderation analyses support our theoretical model. While our results are consistent with the literature, it is also likely that internalized stigma perpetuates or enforces many of these maladaptive traits (Yanos, Roe, Markus, & Lysaker, 2008). Furthermore, the current study included a sample of only male participants. Future research should include both males and females to increase generalizability of findings. Furthermore, there were floor effects on some of our ESM questions (e.g., discrimination), and thus future work may ameliorate this by using daily ESM diary reports for longer periods. Lastly, there may be other factors that may moderate the association between experienced stigma and internalized stigma that we did not assess (e.g., resilience, depression) that might be addressed by future studies.

CONCLUSIONS

The current study extends the literature on discrimination and internalized stigma in PLWH by using an intensive within-person measurement technique (ESM) and suggests that when a person experiences specific incidents of HIV-related discrimination, this may lead to feelings of internalized stigma. Results from this study also provide implications for interventions that aim to modify maladaptive interpersonal traits and/or increase social support to reduce the impact of discrimination on PLWH. Such interventions may help to weaken the link between discrimination and internalized stigma, and in turn reduce poor outcomes in PLWH. Future research is warranted to examine the effectiveness of interventions in reducing internalized stigma in PLWH, and smart-phone technology may be an ideal method for delivering such interventions, including using ESM specifically for measuring adherence as well as predictors and outcomes.