Abstract
Perceived HIV-related stigma continues to persist among people living with HIV and coping strategies are crucial to overall health. Coping may be associated with perceived HIV-related stigma. However, research examining differences by sex and sexual orientation is lacking. Therefore, the aims of the study were to assess the association between ways of coping and perceived HIV-related stigma, and to examine the relationship by sex and sexual orientation. Data were obtained from 346 individuals (191 men and 155 women) living with HIV. Multiple linear regression models showed that overall, distancing, and attack/escape avoidance coping were positively associated with perceived HIV-related stigma among the overall population, among men who have sex with men (MSM), and among women overall and heterosexual women. Among men overall, distancing and attack/escape avoidance coping were positively associated with perceived HIV-related stigma. Among women who have sex with women (WSW), attack/escape avoidance coping was positively associated with perceived HIV-related stigma. There were no statistically significant results among heterosexual men. Effect sizes indicated small effects for overall coping and medium to large effects for distancing and attack/escape avoidance coping. The findings suggest that interventions focused on reducing perceived HIV-related stigma among populations living with HIV should address distancing and attack/escape avoidance strategies especially among women, regardless of sexual orientation, and MSM.
Keywords: coping, stigma, disparities, women, men, HIV, depression, social support, disclosure, MSM
Introduction
HIV stigma continues to be one of the main drivers of the HIV epidemic (Turan, Hatcher, Weiser, Johnson, Rice, & Turan, 2017), persists among individuals living with HIV (Earnshaw, Lang, Lippitt, Jin, & Chaudoir, 2015), and affects HIV care (Shacham, Rosenburg, Onen, Donovan, & Overton, 2015). HIV-related stigma may be enacted (external discrimination or prejudice) or felt/anticipated (internal feelings of guilt, shame, or fear of being discriminated against) (Emlet, 2006; Green & Platt, 1997; Jacoby, 1994). For the purposes of this study, we are interested in how people living with HIV (PLWH) perceive stigma, which is most akin to felt/anticipated stigma, and which we define as perceived HIV-related stigma.
Multiple factors have been found to be associated with perceived HIV-related stigma (Berg, Carter, & Ross, 2017; Brown, Serovich, Kimberly, & Hu, 2016; Radcliffe, Neaigus, Bernard, & Shepard, 2015). Among women living with HIV, psychological reactance was found to be positively associated with perceived HIV-related stigma (Brown et al., 2016). Berg et al. (2017) found that depression was positively and social support was negatively correlated with perceived HIV-related stigma among men who have sex with men (MSM) living with HIV. Among a New York City sample of adults undergoing outpatient HIV care, internalized stigma was associated with being diagnosed after the introduction of highly active antiretroviral therapy in 1996 and a depression diagnosis among women. However, among men in this sample, stigma was associated with younger age and use of non-injection drugs (Radcliffe et al., 2015). These studies also highlight the importance of the consideration of sex differences in examining perceived HIV-related stigma.
Among individuals living with HIV, coping strategies, which may be maladaptive or adaptive, are crucial to overall health and may be associated with their perceived HIV-related stigma. Maladaptive coping may refer to behavioral and/or mental disengagement (Ashton et al., 2005) and rumination (Thompson et al., 2010). Adaptive coping, in contrast, refers to active-approach coping (Fleishman et al., 2003). Among MSM living with HIV, use of more maladaptive coping strategies was associated with more depression and lower use of HIV-related support services (Rood, McConnell, & Pantalone, 2015). Adaptive coping was negatively correlated with enacted and anticipated stigma among PLWH in a Connecticut sample (Earnshaw et al., 2015).
The transactional model of stress and coping (Lazarus & Folkman, 1984) may help to explain the association between coping and perceived HIV-related stigma. The model suggests that, after a stressful event, primary and secondary appraisals occur. Coping styles are then used, with the aim of handling the stressful event, which may in turn influence health behavior. Research has shown that experienced and perceived HIV-related stigma are risk factors for psychological distress (Parcesepe et al., 2018; Rinehart et al., 2019). Therefore, the transactional model of stress and coping may help to explain the relationship between how individuals living with HIV cope and perceived-HIV related stigma.
There are potential sociodemographic confounders, which may alter the association between coping and perceived HIV-related stigma. Age and time since diagnosis have been linked to coping (Brennan, Holland, Schutte, & Moos, 2012; Varni, Miller, McCuin, & Solomon, 2012). A longitudinal study found that as age increased, approach and avoidance coping decreased (Brennan et al., 2012). Disengagement/avoidance coping was found to be negatively associated with time since HIV diagnosis (Varni et al., 2012). Black populations have reported using more coping strategies compared to White populations (Tate, Van Den Berg, Hansen, Kochman, & Sikkema, 2006).
With regard to stigma, younger age has been associated with perceived HIV-related stigma among MSM (Radcliffe et al., 2015). Black women (Rice et al., 2018) and Black men (Cahill et al., 2017) tend to report intersectional stigma (due to race and living with HIV) compared to White populations living with HIV. Emlet et al. (2015) found that time since diagnosis was negatively associated with perceived HIV-related stigma.
Research examining the association between different ways of coping and perceived HIV-related stigma, and the potential differences by sex and sexual orientation is lacking. Therefore, the main aims of this study were to assess the association between ways of coping and perceived HIV-related stigma, and to examine the relationship by sex and sexual orientation. We hypothesized that adaptive coping and maladaptive coping would be negatively and positively associated with perceived HIV-related stigma, respectively.
Methods
Data Source and Study Population
Data for the current study were obtained from 346 participants (191 men and 155 women) living with HIV at the baseline assessment of a longitudinal disclosure intervention study. This intervention was designed to help PLWH in their decisions to disclose their HIV status to their family members. The study took place in a U.S. Southeastern metropolitan statistical area between January 2014 and August 2018, with baseline data collection being completed in September 2017. To be eligible for the intervention study, participants had to be at least 18 years old, living with HIV, expressed an interest in learning more about disclosure and a desire to disclose their HIV status to at least one family member who was not yet aware of their HIV-positive status.
Participants were recruited using advertising at AIDS service organizations, HIV-related venues, in local newspapers, and on social media websites. Audio-computer assisted self-interviewing was used to complete baseline questionnaires. All participants provided written consent to take part in the study and received $50 for participating at baseline. The study was approved by the University of South Florida Institutional Review Board.
Measures
Coping.
Coping was operationalized by the Ways of Coping Scale (Folkman & Lazarus, 1985). Using principal components analysis (PCA), three components (subscales) were obtained: adaptive, distancing and attack/escape avoidance (Brown, Serovich, Laschober, Kimberly, & Lescano, 2019). Four items were deleted from the overall scale due to the PCA. Each item was scored using a Likert-type scale with answers ranging from Does not apply/not used (0) to Used a great deal (3). Items in the revised overall scale, and subscales were summed to obtain sum scores. The standardized Cronbach’s alpha values for the overall scale and subscales are shown in Table 1.
Table 1.
Standardized Cronbach’s Alpha Values for Coping Scale and Subscales, and HIV-Related Stigma Scale
| Measure | Population |
||||||
|---|---|---|---|---|---|---|---|
| Overall | Men | Women | MSM | Heterosexual Men | Heterosexual Women | WSW | |
| Overall Coping Scale | 0.90 | 0.90 | 0.91 | 0.89 | 0.93 | 0.92 | 0.86 |
| Adaptive | 0.92 | 0.92 | 0.92 | 0.91 | 0.95 | 0.93 | 0.89 |
| Distancing | 0.83 | 0.83 | 0.82 | 0.84 | 0.82 | 0.84 | 0.70 |
| Attack/Escape-Avoidance | 0.73 | 0.74 | 0.71 | 0.74 | 0.76 | 0.68 | 0.81 |
| HIV-Stigma Scale | 0.95 | 0.96 | 0.95 | 0.96 | 0.95 | 0.95 | 0.94 |
Perceived HIV-Related Stigma.
Perceived HIV-related stigma was measured by the HIV Stigma Scale (Berger, Ferrans, & Lashley, 2001). This scale contains 40 items, which measure the stigma perceived by PLWH, and has shown to be reliable and valid with diverse populations living with HIV (Berger et al., 2001). Each item was measured using a Likert-type scale with answers ranging from Strongly disagree (1) to Strongly agree (4). Scores of items were summed to obtain a sum score with higher scores indicating greater perceived HIV-related stigma. The standardized Cronbach alpha values are shown in Table 1.
Comorbidity.
Depression was measured using the CES-D, which is a 20-item measure created by Radloff (1977). Responses ranged from “Rarely or none of the time (0) to Most or all of the time (3). Items were summed, with higher scores indicating greater depressive symptoms (Cronbach alpha = 0.91). General health was measured with two summed items, with responses ranging from Definitely False (1) to Definitely True (5) (r = .36). Physical health was measured with four summed items, with responses ranging from Yes, limited a lot (1) to No, not limited at all (3) (Cronbach alpha = 0.83). The latter two variables were subscales from the Health-Related Quality of Life (QOL 601-2) measure created by the AIDS Clinical Trials Group (ACTG, 1999).
Confounders.
Potential sociodemographic confounders that were considered were believed to be associated with coping, were independent risk factors for perceived HIV-related stigma, but were not in the pathway between coping and stigma. Age, race, and time since diagnosis were considered as confounders in the current study.
Analytic Approach
Sociodemographic characteristics were examined in the overall study population, by coping and perceived HIV-related stigma scores (Table 2); and by comorbidity including depressive symptoms, general health, and physical health using descriptive statistics (Table 3). Mean and standard deviation (SD) values were used to examine coping and perceived HIV-related stigma as well as comorbidity. Bivariable correlation values were obtained to measure the correlation between continuous variables of age and time since diagnosis, and coping, perceived HIV-related stigma, and comorbidity. General linear models (GLMs) and associated effect sizes (Eta2) were used to assess differences in means among sociodemographic characteristics. In GLMs, Eta2 = 0.01 (small effect size), Eta2 = 0.06 (medium effect size), and Eta2= 0.14 (large effect size).
Table 2.
Distribution of Sociodemographic Characteristics, Overall Coping and HIV-Related Stigma
| Characteristic | Overall Coping | P-value (Eta2) |
HIV-related Stigma |
P-value (Eta2) |
|
|---|---|---|---|---|---|
| N (%) | Mean (SD) | Mean (SD) | |||
|
Age (Mean, SD) 18–24 25–34 35–49 50+ |
17 (4.9) 51 (14.7) 138 (39.9) 140 (40.5) |
−0.130* 75.1 (16.1) 79.3 (17.9) 73.3 (21.4) 70.2 (18.2) |
0.015 0.038 (0.02) |
−0.071* 106.5 (23.2) 115.1 (21.4) 113.5 (21.9) 107.8 (21.4) |
0.191 0.059 (0.02) |
|
Sex Male Female |
191 (55.2) 155 (44.8) |
72.0 (19.4) 74.2 (19.9) |
0.308 (0.00) |
109.4 (22.8) 113.2 (20.4) |
0.106 (0.01) |
|
Sexual Orientation MSM Heterosexual Men Heterosexual Women WSW |
143 (41.3) 48 (13.9) 128 (37.0) 27 (7.8) |
71.3 (18.4) 74.2 (22.2) 74.2 (20.6) 74.1 (16.1) |
0.611 (0.01) |
108.9 (23.3) 110.8 (21.5) 113.1 (21.1) 113.8 (17.3) |
0.408 (0.01) |
|
Race Black White Other |
196 (57.1) 133 (38.8) 14 (4.1) |
74.6 (21.1) 70.2 (17.1) 75.0 (17.7) |
0.122 (0.01) |
110.5 (20.8) 111.8 (23.8) 114.2 (19.2) |
0.765 (0.00) |
|
Ethnicity Hispanic Non-Hispanic |
42 (12.1) 304 (87.9) |
76.0 (15.6) 72.6 (20.1) |
0.284 (0.00) |
110.2 (24.1) 111.2 (21.6) |
0.781 (0.00) |
|
Education Less than high school High School Some College Bachelor’s/Post-grad |
77 (22.4) 98 (28.5) 131 (38.1) 38 (11.1) |
74.6 (21.0) 75.2 (20.6) 70.9 (17.0) 71.9 (22.3) |
0.341 (0.01) |
113.2 (21.7) 113.8 (20.0) 108.6 (23.3) 108.5 (21.1) |
0.224 (0.01) |
|
Employed Full-time Part-time Student/Retired/Disabled/Unemployed |
38 (11.0) 43 (12.4) 265 (76.6) |
77.2 (16.1) 71.3 (22.7) 72.7 (19.5) |
0.344 (0.01) |
104.2 (22.9) 108.3 (20.4) 112.5 (21.8) |
0.061 (0.02) |
|
Income $0-$500 $500-$1,0000 ≥$1,001 |
110 (31.8) 136 (39.3) 100 (28.9) |
72.9 (20.4) 73.5 (18.7) 72.4 (19.5) |
0.906 (0.00) |
113.4 (22.2) 110.9 (20.8) 108.9 (22.8) |
0.331 (0.01) |
|
Time since diagnosis (Mean, SD) ≤1 year >1 year to ≤5 years > 5 years to ≤10 years >10 years to ≤ 20 years > 20 years |
26 (7.5) 56 (16.2) 72 (20.8) 113 (32.7) 79 (22.8) |
−0.083* 70.6 (21.6) 75.5 (19.2) 75.5 (20.5) 73.6 (20.1) 68.9 (17.0) |
0.123 0.192 (0.02) |
0.022* 103.0 (23.8) 113.6 (21.1) 111.1 (23.2) 111.7 (22.2) 111.1 (19.7) |
0.681 0.360 (0.01) |
Bivariable correlation (r)
Table 3.
Distribution of Sociodemographic Characteristics and Comorbidity: Depressive Symptoms, General Health, and Physical Health among Study Population
| Characteristic | Depressive Symptoms |
P-value (Eta2) |
General Health |
P-Value (Eta2) |
Physical Health | P-value (Eta2) |
|---|---|---|---|---|---|---|
| Mean (SD) | Mean (SD) | Mean (SD) | ||||
|
Age (Mean, SD) 18–24 25–34 35–49 50+ |
−0.087* 27.7 (16.2) 24.4 (12.1) 24.1 (11.4) 21.3 (11.1) |
0.106 0.049 (0.02) |
−0.070* 6.7 (2.4) 6.6 (2.0) 6.0 (2.2) 6.2 (2.1) |
0.191 0.227 (0.01) |
−0.261* 10.2 (2.6) 10.4 (1.9) 9.0 (2.2) 8.7 (2.3) |
<.0001 <.0001 (0.07) |
|
Sex Male Female |
22.4 (11.9) 24.2 (11.4) |
0.146 (0.01) |
6.3 (2.1) 6.0 (2.2) |
0.148 (0.01) |
9.6 (2.3) 8.6 (2.2) |
0.000 (0.04) |
|
Sexual Orientation MSM Heterosexual Men Heterosexual Women WSW |
22.0 (11.8) 23.5 (12.3) 23.5 (10.9) 27.5 (13.3) |
0.149 (0.02) |
6.6 (2.1) 5.5 (2.1) 6.1 (2.1) 5.6 (2.2) |
0.004 (0.04) |
10.0 (2.1) 8.3 (2.3) 8.6 (2.2) 8.8 (2.5) |
<.0001 (0.10) |
|
Race Black White Other |
23.6 (10.9) 22.3 (12.6) 26.1 (14.2) |
0.378 (0.01) |
6.0 (2.1) 6.4 (2.3) 6.3 (2.2) |
0.203 (0.01) |
8.9 (2.2) 9.5 (2.3) 9.8 (2.2) |
0.018 (0.02) |
|
Ethnicity Hispanic Non-Hispanic |
23.95 (12.6) 23.1 (11.6) |
0.284 (0.00) |
6.5 (2.2) 6.1 (2.1) |
0.237 (0.00) |
10.0 (2.0) 9.0 (2.3) |
0.006 (0.02) |
|
Education Less than high school High School Some College Bachelor’s/Post-grad |
26.2 (10.9) 24.1 (10.1) 22.1 (13.0) 18.7 (10.8) |
0.005 (0.04) |
5.6 (1.9) 6.2 (1.9) 6.4 (2.3) 6.4 (2.2) |
0.035 (0.03) |
9.1 (2.0) 8.8 (2.3) 9.3 (2.5) 9.5 (2.3) |
0.332 (0.01) |
|
Employed Full-time Part-time Student/Retired/Disabled/Unemployed |
16.3 (11.6) 20.2 (11.1) 24.7 (11.4) |
<.0001 (0.06) |
7.3 (2.2) 6.9 (1.1) 5.9 (2.1) |
<.0001 (0.06) |
10.8 (1.9) 10.4 (1.9) 8.7 (2.2) |
<.0001 (0.12) |
|
Income $0-$500 $500-$1,0000 ≥$1,001 |
27.2 (11.2) 22.4 (10.5) 19.8 (12.6) |
<.0001 (0.06) |
6.0 (2.0) 6.0 (2.0) 6.7 (2.4) |
0.033 (0.02) |
8.9 (2.4) 8.9 (2.2) 9.6 (2.2) |
0.039 (0.02) |
|
Time since diagnosis (Mean, SD) ≤1 year >1 year to ≤5 years > 5 years to ≤10 years >10 years to ≤ 20 years > 20 years |
−0.032* 27.0 (10.8) 19.6 (11.6) 23.9 (12.0) 22.4 (11.3) |
0.553 0.009 (0.04) |
−0.072* 6.2 (2.6) 6.2 (2.1) 6.6 (2.1) 6.1 (2.1) 5.9 (2.1) |
0.181 0.433 (0.01) |
0.389* 9.9 (2.3) 9.6 (2.4) 9.5 (2.3) 8.8 (2.2) 8.8 (2.1) |
<.0001 0.017 (0.03) |
Bivariable correlation (r)
Four multiple linear regression models were used with each model being specific to the way of coping in order to examine overall and different ways of coping and their relationship to HIV-related stigma. Each model was examined using stigma as the outcome and placing way of coping as the independent variable (overall, adaptive, distancing, attack/escape avoidance), confounders (age, race, time since diagnosis), effect measure modifiers (sex and sexual orientation), and interaction terms (way of coping*sex and way of coping*sexual orientation). Parameter estimates, p-values of interaction terms, and Eta2 values are shown in Table 4. Based on these results, multiple linear regression models were used to assess the associations between stigma overall and different ways of coping, by sex (for men and women), and by sexual orientation [for MSM, heterosexual men, heterosexual women and women who have sex with women (WSW)]. Analyses controlled for age, race, and time since diagnosis and are shown in Table 5. In multiple regression models, Eta2 = 0.02 (small effect size), Eta2 = 0.13 (medium effect size), and Eta2 = 0.26 (large effect size).
Table 4.
Parameter estimates and p-values of interaction terms of coping and sex and sexual orientation in relation to perceived HIV-related stigma
| Interaction | B | p-value | Eta2 |
|---|---|---|---|
| Overall Coping | 0.06 | ||
| Coping*sex | 0.34 | 0.06 | |
| Coping*sexual orientation | −0.19 | 0.216 | |
| Adaptive Coping | 0.02 | ||
| Adaptive*sex | 0.394 | 0.303 | |
| Adaptive*sexual orientation | −0.16 | 0.423 | |
| Distancing Coping | 0.17 | ||
| Distancing*sex | 0.51 | 0.582 | |
| Distancing*sexual orientation | −0.42 | 0.352 | |
| Attack/Escape Avoidance Coping | 0.17 | ||
| Attack/Escape Avoidance*sex | 0.11 | 0.930 | |
| Attack/Escape Avoidance*sexual orientation | −0.10 | 0.868 |
Table 5.
Association between Types of Coping and HIV-related Stigma among the Overall Population, by Sex and Sexual Orientation
| Coping | Crude B (95% CI) | p-value (Eta2) | Adjusted B (95% CI)a | p-value (Eta2) |
|---|---|---|---|---|
|
Overall Population (N=350) |
||||
| Overall Coping | 0.21 (0.10, 0.33) | 0.000 (0.04) | 0.22 (0.10, 0.34) | 0.002 (0.05) |
| Adaptive | −0.04 (−0.20, 0.11) | 0.574 (0.00) | −0.03 (−0.19, 0.12) | 0.484 (0.01) |
| Distancing | 1.23 (0.91, 1.55) | <0.001 (0.14) | 1.31 (0.98, 1.65) | <0.001 (0.16) |
| Attack_EA | 1.92 (1.43, 2.41) | <0.001 (0.15) | 1.97 (1.47, 2.48) | <0.001 (0.16) |
| Men (n=194) | ||||
| Overall Coping | 0.21 (0.04, 0.37) | 0.015 (0.03) | 0.22 (0.05, 0.39) | 0.161 (0.04) |
| Adaptive | −0.09 (−0.30, 0.13) | 0.434 (0.00) | −0.83 (−0.30, 0.14) | 0.940 (0.00) |
| Distancing | 1.32 (0.87, 1.77) | <0.001 (0.15) | 1.43 (0.96, 1.91) | <0.001 (0.16) |
| Attack_EA | 1.97 (1.28, 2.65) | <0.001 (0.15) | 2.06 (1.34, 2.77) | <0.001 (0.15) |
| Women (n=156) | ||||
| Overall Coping | 0.21 (0.05, 0.37) | 0.012 (0.04) | 0.23 (0.07, 0.39) | 0.005 (0.10) |
| Adaptive | −0.00 (−0.22, 0.21) | 0.968 (0.00) | 0.04 (−0.18, 0.25) | 0.124 (0.05) |
| Distancing | 1.09 (0.63, 1.55) | <0.001 (0.12) | 1.15 (0.68, 1.61) | <0.001 (0.18) |
| Attack_EA | 1.91 (1.21, 2.61) | <0.001 (0.16) | 1.86 (1.14, 2.58) | <0.001 (0.19) |
| MSM (n=146) | ||||
| Overall Coping | 0.32 (0.12, 0.53) | 0.002 (0.06) | 0.35 (0.14, 0.56) | 0.038 (0.07) |
| Adaptive | −0.01 (−0.28, 0.26) | 0.925 (0.00) | −0.01 (−0.29, 0.26) | 1.000 (0.00) |
| Distancing | 1.53 (1.03, 2.04) | <0.001 (0.20) | 1.69 (1.16, 2.22) | <0.001 (0.22) |
| Attack_EA | 2.10 (1.28, 2.91) | <0.001 (0.16) | 2.29 (1.44, 3.14) | <0.001 (0.17) |
| Heterosexual Men (n=48) | ||||
| Overall Coping | −0.03 (−0.32, 0.25) | 0.816 (0.00) | −0.03 (−0.34, 0.29) | 0.487 (0.08) |
| Adaptive | −0.24 (−0.60, 0.11) | 0.176 (0.04) | −0.26 (−0.66, 0.13) | 0.236 (0.12) |
| Distancing | 0.58 (−0.40, 1.56) | 0.239 (0.03) | 0.80 (−0.28, 1.87) | 0.226 (0.13) |
| Attack_EA | 1.62 (0.33, 2.91) | 0.015 (0.12) | 0.07 (0.02, 0.13) | 0.094 (0.18) |
| Heterosexual Women (n=129) | ||||
| Overall Coping | 0.20 (0.02, 0.37) | 0.030 (0.04) | 0.20 (0.02, 0.38) | 0.015 (0.10) |
| Adaptive | 0.02 (−0.22, 0.26) | 0.865 (0.00) | 0.04 (−0.19, 0.28) | 0.115 (0.06) |
| Distancing | 1.02 (0.51, 1.53) | <0.001 (0.11) | 1.06 (0.55, 1.58) | <0.001 (0.17) |
| Attack_EA | 1.84 (0.97, 2.70) | <0.001 (0.12) | 1.70 (0.81, 2.59) | <0.001 (0.16) |
| WSW (n=27) | ||||
| Overall Coping | 0.30 (−0.12, 0.73) | 0.156 (0.08) | 0.48 (0.05, 0.90) | 0.228 (0.23) |
| Adaptive | −0.17 (−0.72, 0.37) | 0.518 (0.02) | −0.01 (−0.61, 0.58) | 0.958 (0.03) |
| Distancing | 1.68 (0.54, 2.82) | 0.01 (0.27) | 1.82 (0.60, 3.04) | 0.062 (0.34) |
| Attack_EA | 2.38 (1.34, 3.42) | <0.001 (0.47) | 2.71 (1.92, 3.50) | <0.001 (0.72) |
Controlling for age, race, and time since diagnosis.
Results
Table 1 shows the standardized Cronbach’s alpha values for the overall coping scale and subscales, and for perceived HIV-related stigma. These values indicate that the scales used for the overall population and subgroups had internal consistency values ranging from .68 to .96.
Table 2 shows the distribution of sociodemographic characteristics, overall coping, and perceived HIV-related stigma. Age was negatively correlated with overall coping. Additionally, participants aged 25-34 had higher levels of overall coping compared to participants aged 50 and over. There were no other statistically significant differences by any other sociodemographic characteristic in overall coping, and no statistically significant difference found comparing perceived HIV-related stigma scores. All effect sizes for overall coping and HIV-related stigma by sociodemographic characteristics were small (Eta2 range: 0.00 to 0.02).
Pertaining to comorbidity, overall, participants reported a mean of 23.2 (SD = 11.7) for depressive symptoms (minimum of 0 and maximum of 52); a mean of 6.2 (SD = 2.2) for general health (minimum of 2 and maximum of 10); and a mean of 9.1 (SD = 2.3) for physical health (minimum of 4 and maximum of 12). Table 3 shows the distribution of sociodemographic characteristics and depressive symptoms, general health, and physical health. A number of statistically significant relationships were evident although the effect sizes varied.
Table 4 shows the parameter estimates, p-values, and effect sizes of the interaction terms in each coping model in terms of perceived HIV-related stigma. Interactions were not statistically significant. Interactions with sex and sexual orientation had medium effect sizes for distancing and attack/escape avoidance coping. Main effects with medium effect sizes were found for two ways of coping: distancing coping (B = 1.42, p = 0.018, Eta2 = 0.17) and attack/escape avoidance coping (B = 2.02, p = 0.022, Eta2 = 0.17) were positively related to perceived HIV-related stigma (not shown).
Table 5 shows the association between ways of coping and perceived HIV-related stigma among the overall population and by sex and sexual orientation. After adjusting for age, race, and time since diagnosis, overall, distancing, and attack/escape avoidance coping were positively associated (small to medium effect sizes) with perceived HIV-related stigma among the overall population; women in general; MSM; and heterosexual women. Among men in general, distancing and attack/escape avoidance coping were positively associated with perceived HIV-related stigma (medium effect sizes). Among WSW, only attack/escape avoidance coping was positively associated with perceived HIV-related stigma (large effect size). There was no statistically significant relationship between ways of coping and perceived HIV-related stigma among heterosexual men or between adaptive coping and perceived HIV-related stigma for any group (small effect sizes except for heterosexual men, Eta2=0.12).
Discussion
The main findings of the current study were that overall coping, distancing, and attack/escape avoidance coping were positively associated with perceived HIV-related stigma among the overall study population, and among women, specifically heterosexual women, and MSM. Among men, both distancing and attack/escape avoidance coping were positively associated with perceived HIV-related stigma. Among WSW, only attack/escape avoidance was associated with perceived HIV-related stigma. Contrary to our hypothesis, the association between adaptive coping and perceived HIV-related stigma was not statistically significant for any group.
Nevertheless, the observed effect sizes, in spite of statistical significance, must also be considered in the current findings as they shed light on the meaningfulness and clinical relevance (Page, 2014). Effect sizes indicated small effects for overall coping and medium to large effects for distancing and attack/escape avoidance coping. These findings suggest that interventions focused on reducing perceived HIV-related stigma among populations living with HIV should address the reduction of distancing and attack/escape avoidance strategies.
The findings from our study confirm and contradict previous research. Earnshaw et al. (2015) found that adaptive coping was negatively correlated with perceived HIV-related stigma among PLWH. However, in the current study we did not find a statistically significant association among any group or a clinically significant association among most groups. Albeit non-statistically significant, there was a medium effect size between adaptive coping and perceived HIV-related stigma among heterosexual men (Eta2=0.12). This finding suggests that addressing adaptive coping may help to reduce HIV-related stigma, especially among heterosexual men.
Nevertheless, the findings that maladaptive coping strategies such as distancing and attack/escape-avoidance were associated with perceived HIV-related stigma supports and contradicts previous studies. These associations had statistical and/or clinical significance for all groups, irrespective of sex or sexual orientation (p<0.05 and/or Eta2 ranging from 0.13 to 0.72). Emlet et al. (2013, 2015) found that maladaptive coping as operationalized by selected items in the Brief Cope (e.g., self-distraction, denial, behavioral disengagement; Carver, 1997) was associated with perceived HIV-related stigma among Ontario adults living with HIV. The largest effect sizes in the current study between maladaptive coping and HIV-related stigma were seen for WSW (distancing Eta2=0.34; attack/escape avoidance Eta2=0.72), suggesting high clinical significance. However, another study examining Haitian adults living with HIV did not find a statistically significant association between maladaptive coping and perceived HIV-related stigma (Rubens et al., 2018).
The current study’s findings suggest that the association between maladaptive coping and perceived HIV-related stigma exists for women, including heterosexual women and WSW, and for men, specifically MSM. Even though the association between distancing and perceived HIV-related stigma was not statistically significant for heterosexual men as was seen for the other groups, results for all groups indicated clinical significance (Eta2 ranging from 0.13 to 0.34). These results indicate the importance of addressing maladaptive coping (distancing and attack/escape-avoidance strategies), which may reduce perceived HIV-related stigma among PLWH, irrespective of sex and sexual orientation.
In applying the transactional model of stress and coping, which suggests that coping styles may be linked to behaviors, the model supports the study’s findings of the association between distancing and attack/escape-avoidance and perceived HIV-related stigma. When an individual perceives a stressor, they determine if resources are available to deal with the stressor. When an individual copes by blaming others, distancing themselves or avoiding the situation, these strategies are referred to as emotion-focused coping. Emotion-focused coping refers to methods, which aim to reduce, tolerate or eliminate feelings of stress. Indeed, emotion-focused coping has been found to be positively associated with internalized HIV stigma (Slater et al., 2015) and negatively associated with quality of life (Slater et al., 2013).
There are some limitations to consider in interpreting the study’s findings. First, the study is cross-sectional. Therefore, the temporal sequence between coping and perceived HIV-related stigma could not be determined. Second, participants were recruited from a U.S. Southeastern metropolitan statistical area. As a result, the study population may not be representative of all populations living with HIV. As coping was operationalized using the Ways of Coping Scale, this variable may have a differential impact on perceived HIV-related stigma compared to coping specific with HIV-related illnesses. The sample of WSW (n=27) was also small and so results for this group should be interpreted with caution.
Nevertheless, the study also had several strengths. We were able to examine the impact of different ways of coping, including adaptive and maladaptive strategies on perceived HIV-related stigma, and among multiple groups. Clinical significance, and not merely focusing on statistical significance, was also assessed. Analyses adjusted for the confounding effects of age, race, and time since diagnosis, which may alter the “true association” between coping and perceived HIV-related stigma. Lastly, majority of the Cronbach’s alpha values for coping strategies and perceived HIV-related stigma measures among all groups in the current study ranged from acceptable to excellent (Tavakol & Dennick, 2011).
Conclusion
The current study found positive associations between maladaptive coping and perceived HIV-related stigma among women, regardless of sexual orientation, and MSM. The findings suggest that interventions focused on reducing perceived HIV-related stigma among populations living with HIV should address attack/escape avoidance strategies among these groups. The results also indicate that all groups, except for heterosexual men and WSW, may benefit greatly from interventions aimed at reducing perceived HIV-related stigma via attenuating distancing coping. However, programs addressing adaptive coping may benefit heterosexual men. Future research should focus on examining the relationship between coping specifically related to dealing with HIV-related illnesses and perceived HIV-related stigma to determine if this association persists. The results also found no direct association between adaptive coping and perceived HIV-related stigma among women and MSM. Therefore, future studies may examine potential mediators between adaptive coping and perceived HIV-related stigma to determine alternative pathways leading to perceived HIV-related stigma among these populations. In addition, future research should include more comprehensive, behavior-based studies to assess the impact of coping, perceived HIV-related stigma and their impact on HIV-risk behaviors. The low sample size of WSW also suggests that future studies should oversample this population to gain a better understanding of coping and HIV-related stigma in this understudied population.
Acknowledgements:
This study was funded by the National Institute of Mental Health (R01MH097486) awarded to the second author (JMS). M. J. Brown is funded by the National Institute of Mental Health (K01MH115794). We would like to thank the individuals who participated in this study.
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