Abstract
Research has shown that HIV-related stigma contributes to people living with HIV having a higher risk of mental health disorders. Our study examines the association between enacted HIV-related stigma and symptoms of anxiety and depression among PLWH. We used baseline data from 932 PLWH collected from the Florida Cohort study between 2014–2018. The sample was majority 45+ years of age (63.5%), male (66.0%), and Black (58.1%). The majority had previously experienced enacted HIV-related stigma (53.1%). Additionally, 56.6% and 65.2% showed mild to moderate/severe levels of anxiety and depression, respectively. Those who experienced any levels of enacted HIV-related stigma (vs none) had significantly greater odds of mild and moderate/severe levels of anxiety (vs no/minimal) (AOR[CI]=1.54[1.13, 2.10], p=0.006; AOR[CI]=3.36[2.14, 5.26], p<0.001, respectively) and depression (AOR[CI]=1.61[1.19, 2.18], p=0.002; AOR[CI]=3.66[2.32, 5.77], p<0.001, respectively). Findings suggest a need to evaluate interventions for PLWH to reduce the deleterious effects of enacted HIV-related stigma on mental health.
Keywords: HIV-related stigma, Anxiety, Depression
Resumen
Investigaciones previas han documentado que el estigma relacionado con el VIH contribuye al alto riesgo de trastornos de salud mental entre las personas que viven con VIH. Nuestro estudio examina la asociación entre el estigma declarado y síntomas de ansiedad y depresión entre las personas que viven con VIH. Utilizamos datos de referencia recopilados por el “Florida Cohort Study” de 932 personas que viven con VIH. La mayoría de la muestra sobrepasaba 45 años (63.5%), era masculina (66.0%), y racialmente negra (58.1%). La mayoría había experimentado estigma declarado (53.1%). Además, 56.5% y 65.2% mostro niveles de síntomas leves a moderados/severos de ansiedad y depresión, respectivamente. Aquellos que experimentaron cualquier nivel de estigma declarado (vs ninguno) tenían mayores probabilidades de niveles de síntomas leves y moderados/severos de ansiedad (vs ninguno) (ORa[IC]= 1.54[1.13, 2.10], p=0.006; ORa[IC]= 3.36[2.14, 5.26], p<0.001, respectivamente) y depresión (ORa[IC]= 1.61[1.19, 2.18], p=0.002; ORa[IC]= 3.66[2.32, 5.77], p<0.001, respectivamente). Los resultados sugieren la necesidad de evaluar las intervenciones para las personas que viven con VIH para reducir los efectos nocivos del estigma declarado en la salud mental.
INTRODUCTION
Mental health disorders are one of the most common forms of disability in the United States (U.S.) where 1 in 6 adults will experience depression and a little less than 1 in 3 adults will experience an anxiety disorder during their lifetime (1). In 2018, 12.8% of Florida adults reported poor mental health on 14 or more days during the past month (2). In addition to mental health burden, Florida also accounts for a disproportionate amount of HIV infections, ranking 2nd in both prevalence and incidence in 2018 in the U.S. (3). Previous research among people living with HIV (PLWH) in the U.S. has found that 12.4% had major depression (4) and 19.2% had generalized anxiety disorder (5), in comparison to 7.6% and 2.1% in the general population, respectively (6). These data underscore the pressing need for continued research aimed at understanding the factors contributing to increased rates of mental health disorders faced by PLWH in disproportionately affected states.
One challenge encountered among PLWH is HIV-related stigma. Previous studies among PLWH in the U.S. have found that HIV-related stigma is an important factor in mental health outcomes such as anxiety and depression (5, 7–19). HIV-related stigma can be broken down into 4 main factors: enacted, community, internalized, and anticipated (20). Enacted HIV-related stigma are actions taken against PLWH due to their HIV status, while internalized HIV-related stigma are negative feelings that PLWH harbor about themselves due to their HIV status (20). Community HIV-related stigma are the perceived negative feelings of PLWH by their communities, while anticipated HIV-related stigma are feared consequences of divulging one’s HIV status (20). Our study focused on enacted stigma as we were interested in how experiences of discrimination are associated with mental health outcomes.
In 2010, the World Health Organization published a framework of understanding factors that contribute to mental health conditions (21). The 3 main contributing factors were reduced development (i.e. poverty, population inequity, social capital), increased vulnerability (i.e. stigma, violence, reduced access to health and social services), and worsened mental health (i.e. sleep and eating problems, interpersonal problems, sadness) (21). However, previous literature on correlates of mental health disorders has also found correlates unique to PLWH such as viral load count (13, 14) and years since diagnosis (9, 11, 13, 14).
Enacted HIV-related Stigma and Depression
Three recent studies examined the correlation between depression and enacted HIV-related stigma (9, 11, 19). The study by Crockett et al. (2019) found, that among 199 PLWH recruited from a Ryan White clinic in Central Georgia, enacted HIV-related stigma was significantly associated with depression (9). Additionally, the study by Lipira et al. (2019) found that among 226 Black women recruited from 3 clinical sites in Chicago, Illinois and Birmingham, Alabama, enacted HIV-related stigma was significantly associated with depression (11). However, the study by Felker-Kantor et al. (2019) among 380 PLWH recruited from local HIV-clinics in New Orleans, found that enacted HIV-related stigma was strongly associated with depression but not at the significance level of α=0.05 (19). Though these studies found strong association between HIV-related stigma and depression, two had relatively small sample sizes (9, 11), and one was not statistically significant at α=0.05 (19). Additionally, their findings may not be generalizable due to single site/city recruitment in one study (9, 19), and the inclusion of only Black women and not the general population of PLWH in the other (11).
Enacted HIV-related Stigma and Anxiety
Two recent studies examined the correlation between general anxiety and enacted HIV-related stigma. The study by Beer et al. (2019) found that cumulative HIV-related stigma (including enacted stigma) was significantly associated with the prevalence of general anxiety disorder symptoms using the 2015 Medical Monitoring Project data collected by the Centers for Disease Control and Prevention (5). Additionally, the study by Felker-Kantor et al. (2019) found, among 380 PLWH recruited from local HIV-clinics in New Orleans, enacted HIV-related stigma was significantly associated with anxiety (19).
Though many studies continue to demonstrate the burden of HIV-related stigma on mental health (14), the majority lack specificity of what type of stigma is most detrimental to mental health (i.e. enacted, community, etc.). Studies that examine specific constructs of HIV-related stigma will better inform both state and national strategies to produce more tailored interventions to combat HIV-related stigma. Additionally, the most current research on HIV-related stigma and depression has included small sample sizes with narrow inclusion criteria, which may limit the generalizability of the findings (9, 11). The primary objective of this study is to address these gaps by examining the association of enacted HIV-related stigma with symptoms of anxiety and depression among PLWH in the state of Florida.
METHODS
Participants & Setting
We used baseline data collected from the Florida Cohort study between 2014–2018. As described previously (22), the Florida Cohort Study is overseen by the Southern HIV & Alcohol Research Consortium (SHARC) and has goals to assess factors that affect the health outcomes of PLWH (https://sharc-research.org/). The Cohort recruited from 9 public health sites using venue-based convenience sampling throughout the state of Florida (Alachua County (2 sites), Broward County, Columbia County, Hillsborough County, Miami-Dade County, Orange County, Seminole County, and Sumter County) using brochures and referrals from clinical staff. Participants were eligible for the study if they were living with HIV and ≥ 18 years of age. After obtaining written consent, participants had the option of completing the survey in English or Spanish and at the recruitment site or at home. Surveys were completed online using Research Electronic Data Capture (REDCap) or on paper. Surveys collected data on demographic, behavioral, mental, and social factors. Surveys took approximately 30–45 minutes to complete, and participants received a $25 gift card after completion. The Florida International University, University of Florida, and Florida Department of Health Institutional Review Boards have approved the protocol of this study.
Outcomes of Interest
Anxiety
General anxiety symptoms were measured using the Generalized Anxiety Disorder Screener (GAD-7). Previous studies have found the GAD-7 to have high internal reliability (α=0.93) (23). Participants answered each statement of this 7 item tool using a 4-point Likert scale with options from “Not at all” (0) to “Nearly everyday” (3). Total possible scores could range from 0c21. Anxiety symptom scores were then categorized into levels as no/minimal(0–4), mild (5–9), and moderate/severe (10+) symptoms.
Depression
Depression symptoms were measured using the Patient Health Questionnaire depression scale (PHQ-8). Previous studies, have found the PHQ-8 to have high internal reliability (α=0.89) (24). Participants answered each statement of this 8 item tool using a 4-point Likert scale with options from “Not at all” (0) to “Nearly everyday” (3). Total possible scores could range from 0–24. Depression symptom scores were then categorized into levels as no/minimal (0–4), mild (59), and moderate/severe (10+).
Predictors of Interest
Enacted HIV-related Stigma
Enacted HIV-related stigma was measured using an abbreviated version of the Herek HIV-related stigma measure (α=0.89). The scale included 10, 4-point Likert style questions that assessed experiences of enacted HIV-related stigma, ranging from “never”(0) to “3+ times”(3). Sample items included, “Someone didn’t want to touch me because I have HIV,” “Someone insulted or verbally abused me because I have HIV,” etc. Possible scores could range from 0–30. Based on the total score, participants were stratified into the following levels: never experienced HIV-related stigma (0), experienced low/moderate levels of HIV-related stigma (1–10), and experienced high levels of HIV-related stigma (11+). Similar stratification methods have been used in previous studies (25, 26).
Demographics
Demographic items were self-reported and included age group (18–34, 35–44, 45–54, ≥55), biological sex (male or female), race (White, Black, Other), ethnicity (Hispanic or Non-Hispanic), sexual orientation (heterosexual or non-heterosexual), and nationality (U.S. born or foreign born).
Mental Health Risk Indices
We controlled for potential confounders by creating indices based on previous research in order to decrease collinearity (25, 27, 28). We extracted 11 variables from the survey guided by the model presented by the World Health Organization (2012) (variables listed in appendix 1). All extracted variables were coded so that higher scores corresponded with higher risk of poor mental health outcomes. We then conducted a reliability analysis for all 11 variables and removed all variables that were deleterious to the Cronbach’s alpha (based on an increase in the Cronbach’s alpha if the item were deleted) leaving 8 remaining variables.
Using the 8 remaining variables, we conducted principal component analysis (PCA) with and without a varimax rotation. PCA found 3 factors with an eigenvalue greater than 1 (retained eigenvalue range 1.81–1.09), including: socioeconomic risk (3 variables), social support risk (2 variables), and substance use risk (3 variables) (varimax rotated factor pattern can be found in appendix 2). Factors were added and the standardized scores were categorized into risk tertiles: low, moderate, and high risk (≤25% percentile, 25–50% percentile, >50% percentile, respectively).
HIV-Specific Predictors
Based on previous literature (7, 9, 11, 12), time since HIV diagnosis and viral suppression were included in our analyses as covariates. These data on HIV viral load and time since diagnosis were obtained through linkage to the Enhanced HIV/AIDS Reporting System (eHARS) database in collaboration with the Florida Department of Health. Viral suppression was classified as ≤200 copies/mL.
Analysis
All data were analyzed using SAS (v9.4; SAS Institute Inc., Cary, NC). We examined sample frequencies and percentages to describe the characteristics of the sample by anxiety and depression symptom levels. Chi-Square tests were used to compare proportions. The test for the proportional odds assumption was conducted to determine if ordinal logistic regression was appropriate for the analyses (non-significant results meaning that the change in odds was proportional to each level change in enacted HIV-related stigma and that ordinal logistic regression analysis was appropriate). Then, we conducted two adjusted ordinal logistic regression models where anxiety and depression symptom levels were the outcomes and enacted HIV-related stigma was the predictor of interest. Models were adjusted for demographics and risk factors using the indices described above. To be considered as statistically significant, α was set to 0.05.
RESULTS
Our overall sample consisted of 932 PLWH across the state of Florida, of which the majority were 45+ years of age (63.5%), male (66.0%), Black (58.1%), non-Hispanic (79.7%), and U.S. born (84.0%). From the overall sample, 884 (94.8%) and 877 (94.1%) had complete anxiety and depression symptom outcome measure data, respectively. Those who identified as transgender/ gender non-conforming were removed from the final analysis due to small sample size, leaving a final sample of n=858 and n=855 for anxiety and depression symptom outcomes, respectively. Most of our sample reported low/moderate or high levels of enacted HIV-related stigma (53.1%); moreover, 56.6% and 65.2% showed mild to moderate/severe levels of anxiety and depression symptoms, respectively. The characteristics of our final sample stratified by anxiety and depression symptoms can be found in Table 1.
Table I.
Descriptive baseline sample statistics of the Florida Cohort Study stratified by level of depression & anxiety
| Anxiety | Depression | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| No/minimal symptoms | Mild symptoms | Moderate/severe symptoms | No/minimal symptoms | Mild symptoms | Moderate/severe symptoms | |||||
| n (%) | n (%) | n (%) | χ2 | p | n (%) | n (%) | n (%) | χ2 | p | |
| Age group | 13.20 | 0.040 | 20.03 | 0.003 | ||||||
| 18–34 | 61 (41.5) | 31 (21.1) | 55 (37.4) | 46 (30.9) | 48 (32.2) | 55 (36.9) | ||||
| 35–44 | 75 (42.9) | 42 (24.0) | 58 (33.1) | 51 (29.5) | 67 (38.7) | 55 (31.8) | ||||
| 45–54 | 137 (40.1) | 93 (27.2) | 112 (32.7) | 110 (32.4) | 102 (30.1) | 127 (37.5) | ||||
| ≥55 | 104 (51.5) | 53 (26.2) | 45 (22.3) | 94 (46.5) | 53 (26.2) | 55 (27.2) | ||||
| Race | 3.48 | 0.481 | 2.99 | 0.560 | ||||||
| White | 120 (43.2) | 74 (26.6) | 84 (30.2) | 103 (37.1) | 84 (30.2) | 91 (32.7) | ||||
| Black | 225 (45.0) | 120 (24.0) | 155 (31.0) | 173 (34.7) | 155 (31.1) | 170 (34.1) | ||||
| Othera | 30 (34.9) | 25 (29.1) | 31 (36.0) | 23 (26.4) | 31 (35.6) | 33 (37.9) | ||||
| Ethnicity | 1.44 | 0.487 | 0.31 | 0.857 | ||||||
| Non-Hispanic | 300 (42.8) | 183 (26.1) | 218 (31.1) | 241 (35.5) | 218 (31.2) | 239 (34.2) | ||||
| Hispanic | 77 (46.7) | 36 (21.8) | 52 (31.5) | 60 (36.4) | 52 (31.5) | 53 (32.1) | ||||
| Sex | 0.45 | 0.797 | 5.09 | 0.079 | ||||||
| Male | 252 (44.1) | 146 (25.5) | 174 (30.4) | 216 (37.4) | 175 (30.3) | 186 (32.2) | ||||
| Female | 125 (33.2) | 73 (33.3) | 96 (35.6) | 85 (28.2) | 95 (35.2) | 106 (36.3) | ||||
| Sexuality | 0.34 | 0.842 | 1.50 | 0.472 | ||||||
| Heterosexual | 195 (44.1) | 110 (24.9) | 137 (31.0) | 148 (33.5) | 136 (30.8) | 158 (35.7) | ||||
| Non-heterosexual | 165 (42.4) | 103 (26.5) | 121 (31.1) | 142 (36.5) | 123 (31.6) | 124 (31.9) | ||||
| Nationality | 0.88 | 0.645 | 1.04 | 0.594 | ||||||
| US Born | 311 (42.6) | 188 (25.8) | 231 (31.6) | 252 (34.7) | 223 (30.7) | 252 (34.7) | ||||
| Foreign Born | 62 (47.0) | 31 (23.5) | 39 (29.5) | 46 (35.1) | 45 (34.4) | 40 (30.5) | ||||
| Enacted HIV-related Stigma | 50.12 | <0.001 | 54.48 | <0.001 | ||||||
| None | 207 (52.4) | 91 (23.0) | 97 (24.6) | 174 (44.2) | 114 (28.9) | 106 (26.9) | ||||
| Low/Moderate | 134 (40.7) | 90 (27.4) | 105 (31.9) | 102 (31.3) | 111 (34.0) | 113 (34.7) | ||||
| High | 23 (20.4) | 27 (23.9) | 63 (55.8) | 13 (11.5) | 35 (31.0) | 65 (57.5) | ||||
| Socioeconomic Risk | 16.11 | 0.003 | 19.21 | <0.001 | ||||||
| Low Risk | 141 (51.3) | 59 (21.5) | 75 (27.3) | 112 (41.2) | 89 (32.7) | 71 (26.1) | ||||
| Moderate Risk | 82 (43.6) | 57 (30.3) | 49 (26.1) | 74 (39.4) | 55 (29.3) | 59 (31.4) | ||||
| High Risk | 154 (38.2) | 103 (25.6) | 146 (36.2) | 115 (28.5) | 126 (31.3) | 162 (40.2) | ||||
| Social Support Risk | 90.93 | <0.001 | 73.51 | <0.001 | ||||||
| Low Risk | 169 (64.5) | 50 (19.1) | 43 (16.4) | 137 (53.5) | 67 (26.2) | 52 (20.3) | ||||
| Moderate Risk | 93 (45.6) | 57 (27.9) | 54 (26.5) | 72 (34.6) | 74 (35.6) | 62 (29.8) | ||||
| High Risk | 115 (28.8) | 112 (28.0) | 173 (43.3) | 92 (23.1) | 129 (32.3) | 178 (44.6) | ||||
| Substance Use Risk | 26.76 | <0.001 | 16.37 | 0.003 | ||||||
| Low Risk | 234 (50.8) | 106 (23.0) | 121 (26.2) | 187 (40.7) | 137 (29.8) | 135 (29.4) | ||||
| Moderate Risk | 56 (43.4) | 30 (23.3) | 43 (33.3) | 39 (30.0) | 43 (33.1) | 48 (36.9) | ||||
| High Risk | 87 (31.5) | 83 (30.1) | 106 (38.4) | 75 (27.4) | 90 (32.8) | 109 (39.8) | ||||
| Time Since Diagnosis | 28.59 | <0.001 | 20.66 | <0.001 | ||||||
| <= 1 year | 39 (35.8) | 28 (25.7) | 42 (38.5) | 32 (29.1) | 35 (31.8) | 43 (39.1) | ||||
| 2–5 years | 44 (34.6) | 21 (16.5) | 62 (48.8) | 31 (24.6) | 33 (26.2) | 62 (49.2) | ||||
| 5+ years | 292 (46.9) | 166 (26.6) | 165 (26.5) | 236 (38.2) | 198 (32.0) | 184 (29.8) | ||||
| Virally Suppressed | 3.49 | 0.174 | 4.97 | 0.083 | ||||||
| Yes | 283 (45.6) | 151 (24.3) | 187 (30.1) | 229 (37.1) | 185 (29.9) | 204 (33.0) | ||||
| No | 82 (38.3) | 57 (26.6) | 75 (35.0) | 61 (28.8) | 75 (35.4) | 76 (35.8) | ||||
Bolded values indicate p<0.05,
Included: Native American, Asian, Multiracial, other
Ordinal logistic regression analyses of enacted stigma on level of anxiety
Enacted HIV-related stigma was significantly associated with anxiety symptom levels (χ2= 50.12; p<0.001). The test for the proportional odds assumption for the adjusted ordinal logistic regression was non-significant (χ2= 22.51; p=0.314). Those who have experienced low/moderate or high levels of enacted HIV-related stigma (vs none) had significantly greater odds of higher levels of anxiety symptoms (AOR[CI]= 1.54[1.13, 2.10], p=0.006; AOR[CI]= 3.36[2.14, 5.26], p<0.001, respectively).
Those who had moderate or high social support risk (vs low) (AOR[CI]= 1.99[1.34, 2.96], p<0.001; AOR[CI]= 3.60[2.52, 5.13], p<0.001, respectively), high substance use risk (vs low) (AOR[CI]= 1.43[1.04, 1.97], p=0.029), less than one year or 2–5 years since HIV diagnosis (vs 5+years) (AOR[CI]= 2.00[1.27, 3.15], p=0.003; AOR[CI]= 2.42[1.61, 3.63], p<0.001, respectively) had significantly greater odds of higher levels of anxiety symptoms. Age, race, ethnicity, sex, sexuality, nationality, socioeconomic risk, and viral suppression were not significantly associated with level of anxiety symptoms (Table 2).
Table II.
Adjusted odds ratios and 95% confidence intervals of enacted HIV-related stigma and other selected characteristics on anxiety & depression among a sample of PLWH in Florida
| Anxiety | Depression | |||||
|---|---|---|---|---|---|---|
| AOR | CI | p | AOR | CI | p | |
| Age group | ||||||
| 18–34 | REF | REF | REF | REF | REF | REF |
| 35–44 | 1.15 | 0.72, 1.83 | 0.565 | 1.09 | 0.69, 1.72 | 0.720 |
| 45–54 | 1.38 | 0.89, 2.14 | 0.152 | 1.25 | 0.81, 1.93 | 0.312 |
| ≥55 | 1.00 | 0.61, 1.64 | 0.999 | 0.91 | 0.56, 1.47 | 0.689 |
| Race | ||||||
| White | REF | REF | REF | REF | REF | REF |
| Black | 0.90 | 0.63, 1.27 | 0.531 | 1.02 | 0.73, 1.43 | 0.902 |
| Othera | 1.28 | 0.76, 2.15 | 0.360 | 1.21 | 0.72, 2.04 | 0.472 |
| Ethnicity | ||||||
| Non-Hispanic | REF | REF | REF | REF | REF | REF |
| Hispanic | 0.81 | 0.50, 1.30 | 0.381 | 0.99 | 0.62, 1.59 | 0.967 |
| Sex | ||||||
| Male | REF | REF | REF | REF | REF | REF |
| Female | 1.34 | 0.95, 1.90 | 0.097 | 1.57 | 1.11, 2.21 | 0.011 |
| Sexuality | ||||||
| Heterosexual | REF | REF | REF | REF | REF | REF |
| Non-heterosexual | 1.02 | 0.72, 1.44 | 0.919 | 0.90 | 0.64, 1.26 | 0.535 |
| Nationality | ||||||
| US Born | REF | REF | REF | REF | REF | REF |
| Foreign Born | 1.19 | 0.73, 1.95 | 0.485 | 1.24 | 0.77, 2.02 | 0.378 |
| Enacted HIV-related Stigma | ||||||
| None | REF | REF | REF | REF | REF | REF |
| Low/Moderate | 1.54 | 1.13, 2.10 | 0.006 | 1.61 | 1.19, 2.18 | 0.002 |
| High | 3.36 | 2.14, 5.26 | <0.001 | 3.66 | 2.32, 5.77 | <0.001 |
| Socioeconomic Status Risk | ||||||
| Low Risk | REF | REF | REF | REF | REF | REF |
| Moderate Risk | 1.18 | 0.79, 1.77 | 0.422 | 1.16 | 0.78, 1.73 | 0.458 |
| High Risk | 1.41 | 0.99, 2.01 | 0.058 | 1.66 | 1.16, 2.36 | 0.005 |
| Social Support Risk | ||||||
| Low Risk | REF | REF | REF | REF | REF | REF |
| Moderate Risk | 1.99 | 1.34, 2.96 | <0.001 | 2.02 | 1.38, 2.97 | <0.001 |
| High Risk | 3.60 | 2.52, 5.13 | <0.001 | 3.17 | 2.24, 4.48 | <0.001 |
| Substance Use Risk | ||||||
| Low Risk | REF | REF | REF | REF | REF | REF |
| Moderate Risk | 1.26 | 0.85, 1.87 | 0.257 | 1.48 | 1.00, 2.18 | 0.051 |
| High Risk | 1.43 | 1.04, 1.97 | 0.029 | 1.28 | 0.93, 1.77 | 0.129 |
| Time Since Dx | ||||||
| <= 1 year | 2.00 | 1.27, 3.15 | 0.003 | 1.97 | 1.26, 3.09 | 0.003 |
| 2–5 years | 2.42 | 1.61, 3.63 | <0.001 | 2.50 | 1.66, 3.77 | <0.001 |
| 5+ years | REF | REF | REF | REF | REF | REF |
| Virally Suppressed | ||||||
| Yes | REF | REF | REF | REF | REF | REF |
| No | 1.19 | 0.85, 1.65 | 0.318 | 1.15 | 0.83, 1.60 | 0.402 |
Bold values indicate p<0.05,
Included: Native American, Asian, Multiracial, other
Ordinal logistic regression analyses of enacted stigma on level of depression
The inferential statistics found that enacted HIV-related stigma was significantly associated with depression symptom levels (χ2 =54.48; p<0.001). The test for the proportional odds assumption for the adjusted ordinal logistic regression was non-significant (χ2= 18.25; p=0.571). Those who have experienced low/moderate or high levels of enacted HIV-related stigma (vs none) had significantly greater odds of higher levels of depression symptoms (AOR[CI]= 1.61[1.19, 2.18], p=0.002; AOR[CI]= 3.66[2.32, 5.77], p<0.001, respectively).
Those who identified as female (vs male) (AOR[CI]= 1.57[1.11, 2.21], p=0.011), high socioeconomic status risk (vs low) (AOR[CI]= 1.66[1.16, 2.36], p=0.005), moderate or high social support risk (vs low) (AOR[CI]= 2.02[1.38, 2.97], p<0.001; AOR[CI]= 3.17[2.24, 4.48], p<0.001, respectively), less than one year or 2–5 years since HIV diagnosis (vs 5+ years) (AOR[CI]= 1.97[1.26, 3.09], p=0.003; AOR[CI]= 2.50[1.66, 3.77], p<0.001, respectively) had significantly greater odds of higher levels of depression symptoms. Age, race, ethnicity, sexuality, nationality, substance use risk, and viral suppression were not significantly associated with level of depression symptoms (Table 2).
DISCUSSION
This study continues to bolster association of enacted HIV-related stigma on both levels of anxiety and depression symptoms among a diverse statewide sample of PLWH. The sample had a high prevalence of mild to moderate/severe symptoms for anxiety and depression (56.6% and 65.2%, respectively), consistent with findings from previous studies (6). The primary finding of this study is that enacted HIV-related stigma was significantly associated with higher levels of both anxiety and depression symptoms after adjusting for important confounders, consistent with the majority of current literature (5, 9, 11). However, the study by Felker-Kantor et al. (2019) found a strong association between enacted HIV-related stigma and depression but the association was non-significant in their adjusted model (18). This non-significant finding could be due to high levels of environmental stressors (residential racial segregation, violent crime rates, etc.) among their sample confounding the relationship between HIV-related stigma and depression (18). Our finding bolsters the generalizability of the association between enacted HIV-related stigma and levels of anxiety and depression; however, factors such as environmental stressors should continue to be examined for significance in other populations.
Our study also found that higher social support risk was significantly associated with higher levels of both anxiety and depression symptoms. Previous research among 335 PLWH initially entering outpatient HIV care found that those with higher levels of affectionate social support had significantly lower odds of depression (29). Our findings of social support and enacted HIV-related stigma may further demonstrate the necessity of multi-faceted interventions, as described in previous research (30). Additional research should be conducted to identify which specific constructs of social support are most important in protecting against anxiety and to bolster support for the association between social support and depression for future intervention development.
Additionally, our study also found that shorter time since HIV diagnosis was significantly associated with higher levels of both anxiety and depression symptoms after adjusting for important confounders. Previous qualitative research in the U.S. has highlighted the experiences of PLWH when first testing positive, including feelings of shock, denial, numbness, anger, and sadness (31, 32). Accepting and beginning the process of coping with a positive diagnosis for HIV has been described as the first step of recently diagnosed PLWH in moving on with their lives (33). However, in the provider testing manual developed by the World Health Organization (2011), though attention is given to current emotions and follow-up referrals for confirmatory HIV testing and linkage to care, little emphasis is placed on referrals to community based support groups for PLWH (34). A referral to a community workgroup that utilizes effective, evidence-based strategies could help those recently diagnosed learn about functional coping strategies and living with HIV in the community in which they live (35). Increasing levels of functional coping may prevent the potential manifestation of anxiety and depression derived from the denial and numbness induced by a recent HIV diagnosis, as suggested by previous research (36, 37). Less commonly used stigma intervention approaches, such as community participation interventions that focus on empowerment, should continue be tested for effectiveness (35, 38–40).
Limitations
First, our study may have limited generalizability as we recruited using venue-based convenience sampling and it is not a fully-representative sample of PLWH in Florida. However, the sample was recruited in 9 various locations throughout Florida which may reduce this limitation. Additionally, it is hypothesized that those who agreed to participate in the study may have lower levels of HIV-related stigma as they were willing to participate in a study associated with HIV. Second, our study only included enacted HIV-related stigma questions because other HIV-related stigma factors were not collected. Future studies should utilize validated HIV-related stigma scales that measure multiple constructs of HIV-related stigma. Moreover, the stigma measure did not include a timeline of when enacted stigma occurred (recent or past). Third, we were unable to include transgender/gender non-conforming persons in our analyses due to the low number of transgender/gender non-conforming persons in our sample. Future research on this hard to reach population should be conducted that examines the effects of HIV-related stigma. Fourth, our measures of anxiety and depression measured symptoms, but not clinical diagnoses. However, our study did utilize validated scales to construct the outcomes of anxiety and depression. Lastly, some variables in the model presented by the World Health Organization (2012) were not collected in the study (interpersonal violence, social/gender inequality, nutrition, etc.) and may be important to models predicting mental health outcomes. Future studies should continue to study and report on these factors.
CONCLUSION
Among our sample of PLWH, the majority of participants showed moderate to high levels of anxiety and depression symptoms. Increased enacted HIV-related stigma, social support risk, and more recent time since HIV diagnosis were significantly associated with greater odds of higher levels of both anxiety and depression symptoms. There is a need to develop and evaluate interventions for PLWH and their social support networks intended to reduce the deleterious effects of enacted HIV-related stigma on PLWH. Additionally, a larger emphasis should be placed on organizations that test for HIV to also refer those recently diagnosed with HIV to community workgroups to increase functional coping with the final goal of decreasing levels anxiety and depression.
Supplementary Material
Footnotes
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