Interaction of religion/spirituality with internalized HIV stigma, depression, alcohol use, and sexual risk among Black men who have sex with men: The six city HPTN 061 study

Abstract

Background:

Black men who have sex with men (BMSM) remain at highest risk for HIV in the United States. Internalized HIV stigma and depression contribute to substance use and condomless anal intercourse (CAI). Religion and spirituality (R/S) are associated with decreased HIV-related risk behaviors for some groups, but their impact among BMSM is uncertain. We investigated the main and moderating roles of R/S on pathways from internalized HIV stigma to CAI while under the influence of drugs.

Methods:

We used baseline data from 1511 BMSM from the HIV Prevention Trials Network (HPTN) 061 study to examine the associations between internalized HIV stigma, depressive symptoms, alcohol use, and CAI while under the influence of drugs, adjusting for covariates in generalized structural equation models. We then tested whether R/S moderated the association between (1) internalized HIV stigma and depressive symptoms, (2) depressive symptoms and alcohol use, and (3) alcohol use and CAI while under the influence of drugs.

Results:

Spiritual beliefs (F[1,2]=9.99, p<0.001), spiritual activities (F[1,2]=9.99, p<0.001), and religious attendance (F[1,2]=9.99, p<0.001) moderated the pathway between internalized HIV stigma and depressive symptoms. As internalized HIV stigma increased, those with lower spiritual activity scores experienced significantly higher increases in depressive symptoms compared to those with higher spiritual activity scores whose depressive symptom scores remained unchanged (stigma*spiritual activities B=−0.18 [SE=0.07], p<0.001).

Conclusion:

Religion and spirituality were protective against CAI among BMSM. Future intervention research should explore ways to incorporate religious and/or spiritual activities to reduce internalized HIV stigma as one way to reduce depressive symptoms among BMSM.

INTRODUCTION

In the United States (U.S.) an estimated one-half of Black men who have sex with men (BMSM) will be diagnosed with HIV over their lifetime compared to 9.1% of White MSM.¹ Condomless anal intercourse (CAI)—a behavior often engaged in while under the influence of drugs or alcohol—is a primary risk factor for HIV.^2-4 Individual-level psychosocial vulnerabilities such as internalized HIV stigma, depression, and substance use are associated with CAI while under the influence of drugs.^5,6 However, the complex pathways through which these factors influence CAI among BMSM remains understudied. Moreover, we do not know whether factors such as religion and spirituality have an effect on the association between the psychosocial and behavioral factors that lead to CAI (e.g., internalized HIV stigma to depression).

Extant evidence suggests that internalized HIV stigma, depression, and alcohol and drug use may independently and jointly influence CAI in many ways.^5,7 Internalized HIV stigma is the endorsement of negative beliefs associated with HIV and the application of these beliefs to one’s self and has been shown to increase engagement in HIV risk behaviors.^8-10 Due to social-structural factors like structural racism, societal stigma and negative attitudes, and discriminatory interactions within healthcare and community settings, BMSM experience greater internalized HIV stigma compared with other MSM.^11-14 Due to the stress caused by internalized HIV stigma and related psychosocial factors (e.g., depression), BMSM may engage in negative coping behaviors (e.g., alcohol use, CAI while under the influence of drugs) which heightens their vulnerability to HIV.^14,15 Next, drug and alcohol use prior to or during sex has been shown to increase HIV risk.^5,16-20 Moreover, previous studies among BMSM suggest that HIV risks may be more pronounced when positive forms of coping and support are unavailable in their immediate social-structural environment.^21,22 Further underscoring the need to investigate psychosocial factors that may mitigate or buffer HIV risks among BMSM.

Black Americans in the U.S., including those who identify as MSM, typically have higher levels of religious and spiritual engagement compared to their counterparts of other races.^23-25 Religion is defined here as an organized system of rituals, beliefs, and lifestyles and is often measured by assessing the frequency of attending religious services.^26-29 Spirituality, a broader concept that may or may not function within a specific religious doctrine, characterizes positive psychological states achieved through conscious practices that engage one’s higher internal nature or external sacred belief.^30,31 Religion and spirituality (R/S) are associated with decreased stigma, depression, sexual risk behaviors, and drug and alcohol use.^32-34 However, findings on the strength and direction of these associations for BMSM are mixed^35-37 and complex.^38,39 For example, some studies document that BMSM with greater religious service attendance, a component of R/S, report more experiences of homonegativity, substance use, and HIV-related stigma.^37,40-42 Other studies show that BMSM who attend religious institutions that are supportive of same-sex partnerships report better mental and behavioral health outcomes.⁴³ One reason for these mixed results is that religion is often measured by examining religious service attendance alone, without considering the content of the messages BMSM receive in these services. Turning to spirituality, a preponderance of studies show that MSM report better mental and behavioral health outcomes when they engage in more spiritual activities like prayer and meditation.⁴³ Although the organizational aspects of religion, such as religious service attendance, is a noted source of conflict for BMSM, the role of other non-organizational domains such as spirituality and their potential buffering impact on HIV risks among BMSM, remains understudied.

In this study, hypotheses (see conceptual model in Figure 1 which shows the predicted associations) were informed by theories on how religion and spirituality influence health behaviors and coping strategies.^27,28 We further developed our hypotheses based on theoretical and empirical causal models specific to HIV risk among MSM.^43-45 We examined the association between internalized HIV stigma and depressive symptoms (path1), between depressive symptoms and alcohol use (path 2), and between alcohol use and CAI while under the influence of drugs (path 3). We then tested the hypothesis that R/S would significantly modify the size of associations of each path (e.g., a positive association between internalized HIV stigma and depressive symptoms (path 1)) will be weaker among BMSM with higher R/S compared to those with lower R/S).

Figure 1:

Conceptual Model/Path Diagram Showing Hypothesized Indirect Associations and Interactions

METHODS

Study Participants and Procedures

The current study used baseline data from the HIV Prevention Trials Network (HPTN) 061 study. HPTN 061 was a multisite study conducted between July 2009-December 2011 designed to determine the feasibility and acceptability of a multicomponent HIV prevention program for BMSM (n= 1,553). The study was conducted with a nonprobability sample of BMSM recruited from Atlanta, GA, New York City, NY, Boston, MA, Los Angeles, CA, San Francisco, CA, and Washington, D.C. Men were eligible to participate in the study if they self-identify as a man, or male at birth; identified as Black, African American, Caribbean Black, or multiethnic Black; aged 18 years or older; reported at least one episode of CAI with a man in the past six months; and resided in the metropolitan area. BMSM were recruited from the community or as sexual network partners referred by index participants. Prescreening for eligibility was conducted in person or on the telephone. At the enrollment visit, eligibility was confirmed and written informed consent obtained. Participants used audio computer-assisted self-interview technology to complete a survey that assessed sociodemographic characteristics, behaviors, psychosocial factors, and health. Participants received HIV–STI prevention risk-reduction counseling. A rapid HIV antibody test was conducted and positive rapid tests were confirmed by Western blot testing; HIV positive participants were referred to medical and social services. All study procedures and analyses were approved by the institutional review boards of each research site. More details on study participants and procedures are published elsewhere.^46,47

Measures

Participants reported their sociodemographic characteristics including age in years, education, income, and study site (a proxy for participant location). HIV status was assessed using a rapid HIV antibody test. Participants also reported their religious affiliation and responses were combined into six categories: Baptist, Catholic, Pentecostal, Muslim, other religion, and no affiliation/non-religious.

Internalized HIV stigma was measured with five items such as, “Society looks down on people who have HIV” with responses on a 5-point Likert type scale from 1 (Strongly Disagree) to 5 (Strongly Agree). Scores were summed such that a higher score indicated greater internalized HIV stigma. Cronbach’s α for this sample was 0.74.⁴⁸

Depressive symptoms was assessed using the 20-item Center for Epidemiologic Studies Depression Scale. A depression score was derived by summing responses for participants who answered at least 19 items. Cronbach’s α for this sample was 0.88. Scores were dichotomized such that a score of ≥16 was considered as clinically significant depressive symptoms.⁴⁹

Alcohol use in the past six months was evaluated through a single question: “In the last 6 months, how often did you have a drink containing alcohol?”. Response options included never, monthly or less, 2-4 times a month, 2-3 times a week, and 4 or more times a week.

Spiritual beliefs was derived from four related questions: “Meditation/prayer helps me find solutions to my problems”, “Believing in a higher self/God gives meaning to my life”, “Meditation/prayer makes me feel better”, and “Events in my life reflect an overall purpose and plan”.⁵⁰ Responses were captured using a 5-point Likert type scale from 1 (Strongly Disagree) to 5 (Strongly Agree). A structural equation measurement model (i.e., exploratory factor analysis) was developed to estimate a spiritual beliefs index score in the sample. Cronbach’s α for spiritual beliefs was 0.80.

Spiritual activities was derived from four related questions: “How often do you do personal meditation or prayer?”, “How often do you read spiritual or metaphysical literature?”, “How often do you talk to others about spiritual concerns?”, and “How often do you consult a spiritual or religious leader?”⁵⁰ Response options for these items were never, occasionally, monthly, weekly, and daily. Following the approach for spiritual beliefs, we estimated a spiritual activities index score in the sample. Cronbach’s α for spiritual activities was 0.80.

Religious service attendance was assessed with a single question: “How often do you attend religious or spiritual services?”. Response options were never, holidays, monthly, weekly, and daily. There is some variation in the literature on how to treat responses to this item. Due to the sample size and distribution of responses, we combined weekly and daily attendance to create a variable with four levels (1= never, 2= holidays, 3= monthly, 4= weekly/daily).

CAI while under the influence of drugs was defined as condomless anal sex (bottom or top sexual position, no condom) with the most recent anal sex partner while under the influence of drugs (defined as drug use within a two-hour period before or during sex).

Statistical Analysis

We calculated frequency distributions for categorical variables and means with standard deviations for continuous variables to assess the sociodemographic characteristics of the sample. We conducted bivariate analysis using a Chi-square test, t-test, or related non-parametric test to compare participants engaging and not engaging in CAI while under the influence of drugs on each variable of interest. Next, we tested the associations between internalized HIV stigma, depressive symptoms, alcohol use, and CAI while under the influence of drugs (see Figure 1). We then examined the moderation effects of spiritual beliefs, spiritual activities, and religious service attendance on each path by fitting generalized structural equation models (GSEM) and included the following covariates: study location, HIV status, age, education, marriage status, and household income. We assessed the statistical significance of the main effects at p<0.05 and effect modification at p<0.10 to detect any evidence of an interaction.^51,52 We conducted all statistical analyses using STATA version 14.0.

RESULTS

Twenty six percent of men reported condomless anal intercourse (CAI) while under the influence of drugs. Sociodemographic characteristics associated with CAI while under the influence of drugs were older age, lower education, income, unstable employment status, sexual orientation status, and religious affiliation. Sociodemographic characteristics for the sample are reported elsewhere.⁴⁶ Higher alcohol use frequency and depressive symptoms were also associated with CAI while under the influence of drugs (Table 1). For the main association paths, spiritual activities (β= −1.65; 95% CI= −2.64, −0.65; p= 0.001) was associated with lower depressive symptoms. None of the R/S variables were directly associated with CAI while under the influence of drugs (Table 2).

Table 1.

Demographic Characteristics of HPTN 061 Study Participants (N=1511)

Variable	Total (n=1511) N (%)	Had CAIa (n=388) N (%)	X2/t- value	P-valueb
Age at enrollment (Mean, SD)	37.8, 11.8	41.2, 10.5	−6.68	<0.001*
Education			4.16	0.04*
Less than college	828 (54.8)	230 (59.3)
Greater than high school	682 (45.2)	158 (40.7)
Income			13.8	0.001*
<$9,999	573 (38.3)	169 (43.6)
$10,000-49,999	753 (50.3)	193 (49.7)
>$50,000	170 (11.4)	26 (6.7)
Employment status			5.56	0.02*
Working currently	465 (30.8)	101 (26.0)
Not working currently	1045 (69.2)	287 (74.0)
Marital status			0.04	0.84
Married, have primary partner	171 (11.3)	45 (11.6)
Single, divorced, widowed	1339 (88.7)	343 (88.4)
Sexual orientation			23.4	<0.001*
Homosexual/Gay	516 (34.8)	99 (25.9)
Exclusively bisexual	424 (28.6)	140 (36.7)
Other	545 (36.7)	143 (37.4)
Identify as transgender	31 (2.05)	6 (1.55)	0.66	0.42
HIV status			2.00	0.16
HIV−	1164 (77.0)	309 (79.6)
HIV+	347 (23.0)	79 (20.4)
Location			14.6	0.001*
Southeast	501 (33.2)	99 (25.5)
Northeast	530 (35.1)	158 (40.7)
West	480 (31.8)	131 (33.8)
Alcohol drinking frequency			58.5	<0.001*
Never	319 (21.37)	50 (13.1)
Monthly or less	251 (16.81)	57 (14.9)
2-4 times a month	366 (24.51)	86 (22.5)
2-3 times a week	320 (21.43)	87 (22.7)
4 or more times a week	237 (15.87)	103 (26.9)
Marijuana use in the last 6 months	821 (55.85)	295 (78.5)	104.7	<0.001*
Internalized HIV stigma (Mean, SD)	15.1, 4.4	15.2, 4.3	−0.55	0.58
Depressive symptoms (Mean, SD)	16.3, 11.1	18.1, 10.8	7.06	0.008*
Low risk (<16)	774 (55.4)	180 (49.5)
High risk (≥16)	623 (44.6)	184 (50.6)
Religious affiliation			4.47	0.48
Baptist	306 (46.6)	77 (51.7)
Catholic	42 (6.4)	8 (5.4)
Pentecostal	71 (10.8)	18 (12.1)
Muslim	21 (3.2)	5 (3.4)
Other	172 (26.2)	30 (20.1)
No affiliation/non-religious	45 (6.9)	11 (7.4)
Spiritual beliefs (Mean, SD)	−0.0004, 0.95	−0.0005, 0.90	0.003	1.00
Spiritual activities (Mean, SD)	−0.001, 0.92	−0.008, 0.86	0.17	0.87
Religious service attendance			8.02	0.05*
Never	401 (27.0)	108 (28.3)
Holidays	274 (18.5)	63 (16.5)
Monthly	353 (23.8)	108 (28.3)
Weekly/Daily	455 (30.7)	103 (27.0)

^a.CAI is defined as having condomless anal intercourse (bottom/top position, no condom) with the most recent anal sex partner while under the influence of drugs.

^b.P-value from Chi-square test or t-test comparing respondents having CAI and not having CAI.

Table 2.

Main Associations between Spiritual Activities, Beliefs, and Religious Service Attendance and Depressive Symptoms, Alcohol Use, and CAI while under the Influence of Drugs

Path Coefficients	Estimate [95%CI]	SE	P-value
DV: Depressive Symptoms
Spiritual activities	−1.65 [−2.64, −0.65]	0.51	0.001*
Spiritual beliefs	−0.76 [−1.63, 0.10]	0.44	0.08
Religious service attendance
Never	Reference	Reference	Reference
Holidays	0.10 [−1.67, 1.88]	0.91	0.91
Monthly	0.34 [−1.41, 2.09]	0.89	0.70
Weekly/Daily	0.65 [−1.20, 2.51]	0.95	0.49
Internalized HIV stigma	0.47 [0.34, 0.60]	0.07	<0.001*
Intercept	8.89 [6.51, 11.27]	1.21	<0.001*
DV: Alcohol Use
Spiritual activities	0.003 [−0.12, 0.13]	0.06	0.96
Spiritual beliefs	0.08 [−0.02, 0.19]	0.06	0.13
Religious service attendance
Never	Reference	Reference	Reference
Holidays	0.14 [−0.08, 0.36]	0.11	0.23
Monthly	0.08 [−0.13, 0.30]	0.11	0.45
Weekly/Daily	−0.22 [−0.45, 0.02]	0.12	0.07
Depressive symptoms	0.01 [0.001, 0.01]	0.003	0.02*
Intercept	2.84 [2.65, 3.02]	0.09	<0.001*
DV: CAI
Alcohol use	0.26 [0.18, 0.34]	0.04	<0.001*
Spiritual activities	−0.01 [−0.19, 0.18]	0.09	0.93
Spiritual beliefs	−0.02 [−0.18, 0.14]	0.08	0.77
Religious service attendance
Never	Reference	Reference	Reference
Holidays	−0.24 [−0.57, 0.09]	0.17	0.15
Monthly	0.09 [−0.21, 0.40]	0.15	0.55
Weekly/Daily	−0.18 [−0.53, 0.17]	0.18	0.31
Internalized HIV stigma	0.02 [−0.01, 0.04]	0.01	0.20
Depressive symptoms	0.01 [−0.003, 0.02]	0.005	0.16
Intercept	−3.63 [−4.36, −2.90]	0.37	<0.001*
Location
Southeast	Reference	Reference	Reference
Northeast	0.39 [0.12, 0.66]	0.14	0.01*
West	0.31 [0.02, 0.59]	0.14	0.03*
Age at enrollment	0.03 [0.02, 0.04]	0.005	<0.001*
Income
<$9,999	Reference	Reference	Reference
$10,000–$49,999	−0.19 [−0.41, 0.02]	0.11	0.08
>$50,000	−0.58 [−1.03, −0.12]	0.23	0.01*

Tests for the overall interaction showed that spiritual beliefs (Chi-square= 54.7, p<0.001) and activities (Chi-square= 65.84, p<0.001) as well as religious service attendance (Chi-square= 8.98, p= 0.03) significantly moderated the pathway between internalized HIV stigma and depressive symptoms (Table 2). At the mean of spiritual beliefs, every one standard deviation increase in internalized HIV stigma was associated with a 0.13 increase in depressive symptoms (β= 0.13; 95% CI= −0.01, 0.26; p= 0.07). The association between internalized HIV stigma and depressive symptoms was weaker among those at the mean or higher of spiritual activities (β= −0.18; 95% CI= −0.32, −0.05; p= 0.01). The association between internalized HIV stigma and depressive symptoms was weaker among those who attended religious services weekly (β= −0.48; 95% CI= −0.81, −0.15; p= 0.004) or monthly (β= 0.42; 95% CI= −0.79, −0.05; p= 0.03), compared with those who never attended religious services (Table 3).

Table 3.

Spiritual Beliefs, Activities, and Religious attendance Moderate the Association between Internalized HIV Stigma and Depressive Symptoms among Black MSM in the HPTN 061 Cohort

Path Coefficients, Estimate [95% Confidence Interval (CI)]
	Spiritual beliefs	Spiritual activities	Religious service attendance
DV: Depressive Symptoms
Spiritual activities	−1.66 [−2.65, −0.67]	1.07 [−1.13, 3.28]	−1.69 [−2.68, −0.70]
Spiritual beliefs	−2.70 [−4.95, −0.44]	−0.85 [−1.71, 0.02]	−0.83 [−1.70, 0.03]
Religious service attendance (Reference, Never)
Holidays	0.17 [−1.61, 1.94]	0.16 [−1.61, 1.93]	4.80 [−1.95, 11.55]
Monthly	0.37 [−1.38, 2.11]	0.38 [−1.36, 2.12]	6.72 [0.80, 12.64]
Weekly/Daily	0.70 [−1.16, 2.56]	0.68 [−1.17, 2.53]	7.97 [2.61, 13.34]
Internalized HIV stigma	0.48 [0.35, 0.62]	0.47 [0.34, 0.60]	<0.001*
Spiritual beliefs interaction with Internalized HIV stigma	0.13 [−0.01, 0.26]	-	-
Spiritual activities interaction with Internalized HIV stigma	-	−0.18 [−0.32, −0.05]	-
Religious service attendance interaction with Internalized HIV stigma	-	-	-
Holidays*Internalized HIV stigma	-	-	−0.31 [−0.73, 0.12]
Monthly*Internalized HIV stigma	-	-	−0.42 [−0.79, −0.05]
Weekly/Daily*Internalized HIV stigma	-	-	−0.48 [−0.81, −0.15]
DV: Alcohol Use
Spiritual activities	0.01 [−0.12, 0.13]	−0.02 [−0.19, 0.15]	0.002 [−0.12, 0.13]
Spiritual beliefs	0.11 [−0.04, 0.27]	0.08 [−0.03, 0.19]	0.08 [−0.02, 0.19]
Religious service attendance (Reference, Never)
Holidays	0.13 [−0.09, 0.36]	0.14 [−0.09, 0.36]	0.08 [−0.30, 0.47]
Monthly	0.08 [−0.14, 0.30]	0.08 [−0.14, 0.30]	−0.03 [−0.41, 0.34]
Weekly/Daily	−0.22 [−0.45, 0.01]	−0.22 [−0.45, 0.01]	−0.12 [−0.47, 0.23]
Depressive symptoms	0.01 [0.001, 0.01]	0.01 [0.001, 0.01]	0.01 [−0.00, 0.02]
Spiritual beliefs interaction with Depressive symptoms	−0.002 [−0.01, 0.005]		0.59
Spiritual activities interaction with Depressive symptoms	-	0.001 [−0.01, 0.01]	-
Religious attendance interaction with Depressive symptoms	-	-	-
Holidays*Depressive symptoms	-	-	0.003 [−0.02, 0.02]
Monthly*Depressive symptoms	-	-	0.01 [−0.01, 0.03]
Weekly/Daily*Depressive symptoms	-	-	−0.01 [−0.02, 0.01]
DV: CAI
Spiritual activities	−0.001 [−0.19, 0.18]	−0.22 [−0.55, 0.10]	−0.002 [−0.19, 0.18]
Spiritual beliefs	0.05 [−0.27, 0.36]	−0.02 [−0.17, 0.14]	−0.02 [−0.18, 0.14]
Religious service attendance (Reference, Never)
Holidays	−0.26 [−0.59, 0.08]	−0.26 [−0.59, 0.07]	−0.35 [−1.28, 0.58]
Monthly	0.08 [−0.22, 0.39]	0.08 [−0.22, 0.39]	0.20 [−0.53, 0.93]
Weekly/Daily	−0.19 [−0.54, 0.16]	−0.19 [−0.54, 0.16]	−0.68 [−1.44, 0.09]
Alcohol use	0.25 [0.18, 0.33]	0.26 [0.18, 0.33]	0.22 [0.08, 0.36]
Spiritual beliefs interaction with Alcohol use	−0.02 [−0.10, 0.06]
Spiritual activities interaction with Alcohol use		0.07 [−0.01, 0.15]
Religious service attendance interaction with Alcohol use	-	-	0.03 [−0.22, 0.28]
Holidays* Alcohol use	-	-	−0.03 [−0.23, 0.16]
Monthly* Alcohol use	-	-	0.15 [−0.06, 0.35]
Weekly/Daily* Alcohol use	-	-
Internalized HIV stigma	0.02 [−0.01, 0.04]	0.02 [−0.01, 0.04]	0.02 [−0.01, 0.04]
Depressive symptoms	0.01 [−0.003, 0.02]	0.01 [−0.003, 0.02]	0.01 [−0.002, 0.02]
Location (Reference, Southeast)
Northeast	0.39 [0.12, 0.66]	0.39 [0.12, 0.66]	0.40 [0.12, 0.67]
West	0.31 [0.03, 0.60]	0.32 [0.04, 0.60]	0.32 [0.04, 0.61]
HIV status (Reference, HIV−)
HIV+	−0.07 [−0.33, 0.18]	−0.07 [−0.33, 0.18]	−0.08 [−0.33, 0.18]
Age at enrollment	0.03 [0.02, 0.04]	0.03 [0.02, 0.04]	0.03 [0.02, 0.04]
Education (Reference, Less than college)
Greater than high school	−0.13 [−0.35, 0.09]	−0.13 [−0.35, 0.09]	−0.12 [−0.34, 0.10]
Marriage status (Reference, single/divorce/widowed
Married, have primary partner	0.03 [−0.29, 0.36]	0.05 [−0.28, 0.37]	0.03 [−0.30, 0.35]
Income (Reference, <$9,999)
$10,000–$49,999	−0.17 [−0.39, 0.05]	−0.17 [−0.39, 0.05]	−0.16 [−0.39, 0.06]
>$50,000	−0.52 [−0.99, −0.05]	−0.52 [−0.99, −0.05]	−0.50 [−0.98, −0.03]

To graphically illustrate how the size of associations between internalized HIV stigma on depressive symptoms changes as a function of R/S we plotted predicted depressive symptoms scores for continuous internalized HIV stigma on risk of depressive symptoms, stratified by multiple discrete values of spiritual beliefs and spiritual activities, after adjustment for covariates.^53,54 For clarity, we displayed discrete values for low spiritual beliefs (−1) and high spiritual beliefs (2), which are the extreme lower and upper distribution from each scale. As shown in Figure 2, internalized HIV stigma was positively associated with depressive symptoms among those reporting both high and low levels of spiritual beliefs, although this relationship was stronger among those reporting high spiritual beliefs (indicated by a slightly steeper slope). Importantly, those with higher spiritual beliefs reported lower depressive symptom scores at each level of internalized HIV stigma compared with those with lower spiritual beliefs (i.e., lower intercepts). A slightly different pattern was observed with respect to spiritual activities. Those with high spiritual activities reported lower depressive symptom scores than those with low spiritual activities, and these scores increased at a much lower rate than those with low spiritual activities as internalized HIV stigma score increased from 6 to 18. Finally, with respect to religious service attendance, those who attended services weekly or daily reported higher depressive symptom scores at lower levels of internalized HIV stigma compared with those who never attended service. However, the rate of increase in depressive symptoms as a function of internalized HIV stigma was sharper among those who never attended religious services.

Figure 2.

Plots Showing that Religion and Spirituality Moderates the Association between Internalized HIV Stigma and Depressive Symptoms

DISCUSSION

Religion and spirituality (R/S) are important psychosocial coping resources for BMSM.^14,44,55 While religious service attendance is a noted source of conflict for BMSM, we focus on spirituality, vis-à-vis spiritual activities and beliefs, as another way to engage BMSM to improve adherence and success in ongoing and validated HIV prevention strategies.

Internalized HIV stigma is a significant predictor of sexual risk behaviors, with depressive symptoms and alcohol use as likely mechanisms for these risks. In this study, we simultaneously modeled the associations among internalized HIV stigma, depressive symptoms, alcohol use, and CAI while under the influence of drugs. We then tested hypotheses that R/S will moderate the associations between these variables (Figure 1) within a sample of BMSM residing in the U.S. Consistent with other studies, we found that higher internalized HIV stigma was associated with higher depressive symptoms, higher depressive symptoms was associated with higher alcohol use, and higher alcohol use was associated with an increased likelihood of CAI while under the influence of drugs.^5,10,20

Although higher internalized HIV stigma was associated with greater depressive symptoms, this effect was significantly lower among people with higher spiritual beliefs. Spiritual beliefs also had a similar effect of changing the association between depressive symptoms and alcohol use. R/S did not moderate later stages of the model such as between alcohol use and CAI while under the influence of drugs. Collectively, these findings suggest that R/S may indirectly lower engagement in risk behaviors by disrupting the psychosocial processes (i.e., depression) underlying these behaviors, rather than by altering the substance use or behavioral pathways directly.^56,57 Turning specifically to spirituality, the items in our measure of spirituality reflect a broader definition consistent with oneness and striving to better oneself, rather than reverence to the sacred, which may provide more latitude to develop interventions that meet the needs of both religious and non-religious BMSM.²⁸ We suggest that spirituality informed intervention components could focus on providing BMSM tools to cultivate purpose and spiritual support. These components could be added to existing evidence-based strategies or as stand-alone interventions. However, before interventions are developed, qualitative studies are needed to provide a deeper understanding of how BMSM experience the health benefits of R/S.

Internalized HIV stigma leads individuals to feel socially devalued and to experience a diminished self-worth. For BMSM in this study, internalized HIV stigma manifested itself when they believed the negative views that society holds about HIV and people living with HIV. Spirituality may alter people’s value system to buffer against these negative experiences because it engenders a sense of wholeness and enables people to view themselves and their experiences as part of a meaningful process.^29,43 Perhaps BMSM with greater spirituality are able to replace or challenge negative internalizations with more spiritually positive thoughts about well-being and self-worth.⁵⁸

This study has several limitations. First, the cross-sectional nature of these data means that causal inference among the pathways and temporality cannot be established. For example, BMSM experiencing increased alcohol use may turn away from religion because of religious restrictions and stigma related to alcohol use or they may turn to alcohol to cope with the homonegativity experienced in their religious settings.^29,42,59 Our measure of R/S did not account for participants’ who were religious in the past, but are no longer religious because of non-acceptance, religious trauma, or other reasons.^37,42,43 As such, we are unable to determine whether internalizations of religious objections to sexual minorities are countered by participating in more MSM affirming religious environments.⁴⁰ These nuances have implications for how R/S may influence later paths in our model as well as alcohol use trajectories for BMSM. Additionally, these data were collected between 2009 and 2011, which is a noted limitation. However, HPTN 061 remains one of the largest probability samples of BMSM in the U.S. and therefore provides the most robust data available to assess the proposed associations. Second, men were enrolled in the study based on an eligibility requirement of CAI and thus are not representative of all BMSM, but nonetheless represent a high-risk subgroup for which interventions are needed. Third, our hypotheses and conclusions are based on the specific set of R/S measures captured in the original survey. R/S is a complex experience and may be operationalized through multidimensional constructs (i.e., there may be other R/S variables that operate through specific mechanisms not captured in our measure).²⁷ Moreover, R/S beliefs and activities evolve over time and are influenced by secular and non-secular factors.⁶⁰ Lastly, we assessed effect modification at p<0.10 rather than the typical p<0.05. One of the interactions we found was significant at p<0.07, nevertheless, the lower bound of the effect size (β= 0.13) was −0.01. Interactions may be missed by not having a fully specified model or by not including observed confounders; more often interactions are missed due to sample size. Our results from this interaction test are therefore not prescriptive, but indicative that future research should examine these mechanisms with a larger sample. Despite these limitations, our study used robust measures of R/S, focused on the mechanisms undergirding CAI while under the influence of drugs, and used data from one of the largest-ever studies of BMSM in the U.S. More research is needed to understand how spirituality operates in the context of internalized HIV stigma and to further investigate the heterogeneity in religious services that BMSM attend based on the extent to which they are affirmative of sexual minorities.

CONCLUSIONS

To our knowledge, this is the first study to show empirically that the association between internalized HIV stigma and depressive symptoms was significantly lower among people with higher spiritual beliefs. We used a robust structural equation modeling approach to examine the associations among internalized HIV stigma, depressive symptoms, alcohol, and CAI while under the influence of drugs and how pathways among these variables may be modified by religion and spirituality. These results may be valuable in developing strategies to reduce the effect of internalized HIV stigma on depressive symptoms and contribute to HIV prevention and treatment efforts that aim to reduce alcohol use and CAI while under the influence of drugs. HIV-related intervention strategies that seek to facilitate a sense of meaning, global life purpose, and connectedness to others may be well-suited to including spirituality to address the effects of internalized HIV stigma on depression.⁶¹ Our study further underscores the need to examine internal manifestations of R/S above and beyond the self-reports of attending religious services or denomination affiliation. More specifically, future research could examine the content of religious and spiritual messages to which BMSM are exposed across the life course, both inside and outside of formal religious services, and seek to understand how these messages are internalized to affect HIV risks.⁶² Future studies may also focus on identifying the specific elements of R/S that confer the most positive effects on HIV risks and their psychosocial antecedents, and examine how these elements might be integrated into existing secular interventions for BMSM.