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. Author manuscript; available in PMC: 2023 Apr 1.
Published in final edited form as: Drug Alcohol Depend. 2022 Feb 17;233:109364. doi: 10.1016/j.drugalcdep.2022.109364

Effects of intersecting internalized stigmas and avoidance on HIV and alcohol-related outcomes among people living with HIV in South Africa

Kristen S Regenauer a, Mary B Kleinman a, Jennifer M Belus b,c,a, Bronwyn Myers d,e,f, John A Joska g, Jessica F Magidson a
PMCID: PMC8978067  NIHMSID: NIHMS1783995  PMID: 35219998

Abstract

Background:

Despite HIV and problematic drinking often co-occurring in South Africa (SA), limited research has examined how HIV stigma relates to alcohol outcomes, how alcohol stigma relates to HIV outcomes, or moderators of these associations. This study examined the intersection of HIV/alcohol stigmas on HIV/alcohol outcomes and the role of avoidant behavior in moderating these relationships in SA.

Methods:

We assessed biomarker-verified measures of antiretroviral therapy (ART) adherence, HIV viral load (VL), and alcohol consumption, and self-reported measures of internalized HIV/alcohol stigmas, avoidant behavior, ART adherence, and problematic drinking—alcohol use that will likely lead to health or other problems—cross-sectionally among people with HIV (PWH) and problematic drinking (N=64). Regression analyses with interaction terms were conducted.

Findings:

A significant relationship was found between internalized alcohol stigma and VL suppression, with higher levels of alcohol stigma associated with a lower likelihood of suppression (OR=1.68, 95%CI[1.11–2.65], p=0.02). Avoidance significantly moderated the relationship between internalized HIV stigma and problematic drinking. Higher HIV stigma was associated with lower problematic drinking only at low levels of avoidance (b(SE)=−1.92(.85), p=0.03).

Conclusions:

This study is the first to examine associations between HIV and alcohol stigmas, avoidance, and both HIV and alcohol outcomes in SA. Findings contribute to our understanding of how alcohol stigma relates to biological HIV outcomes, and the role of avoidance in the relationship between internalized HIV stigma and problematic drinking. Findings may inform future clinical interventions to reduce the impact of stigma on HIV treatment outcomes and alcohol use among PWH in SA.

Keywords: stigma, HIV, alcohol use, antiretroviral therapy (ART) adherence, global mental health, South Africa

1. Introduction

Despite having the largest antiretroviral therapy (ART) program globally, HIV incidence remains high in South Africa (SA), driven partly by ART nonadherence (UNAIDS, 2019). Drug resistance resulting from suboptimal adherence can lead to severe health consequences in this setting, as very limited ART regimens are available (Moorhouse et al., 2019). Problematic drinking—alcohol use that will likely lead to health or other problems (Humeniuk et al., 2010)—is prevalent among people with HIV (PWH) in SA (Necho et al., 2020) and contributes to worse adherence and HIV viral load (VL) non-suppression (Myers et al., 2021; Velloza et al., 2020).

HIV stigma is a well-established global barrier to successful HIV outcomes, including ART adherence (Katz et al., 2013). There is also growing evidence that alcohol-related stigma is associated with poor alcohol-related outcomes, such as low alcohol treatment engagement (Brener et al., 2010; Keyes et al., 2010; Kulesza et al., 2013; Myers et al., 2009). Yet, despite the common co-occurrence of HIV and problematic drinking in SA, limited research has examined how HIV stigma may affect problematic drinking or how alcohol stigma may affect ART adherence in this context. Among PWH in SA, there is emerging evidence that people may use alcohol to cope with internalized HIV stigma (Regenauer et al., 2020), and that stigma around drinking while on ART may partially mediate the relationship between drinking and adherence (Kalichman et al., 2020). However, quantitative examinations of such associations are sparce (Edelman et al., 2017; Lunze et al., 2017). Even less research has quantitatively examined the potential intersecting effects of HIV/alcohol stigmas—the effect multiple converging stigmas has on health behaviors (Bowleg, 2012; Turan et al., 2019). This gap is important to address, given the amplifying effects converging stigmas may have on health outcomes (Bauer, 2014; Turan et al., 2019). While stigma can exist on multiple levels, internalized stigma—the self-endorsement of negative beliefs about a stigmatized identity (Earnshaw & Chaudoir, 2009)—may be a modifiable individual-level intervention target, as it focuses on the perception of oneself as opposed to actions of others.

Prior conceptual models (Leach & Cidam, 2015) suggest behaviors that lead to poorer health outcomes are often avoidant in nature (e.g., care non-engagement). Internalized stigma may lead to poor health behaviors among PWH with high avoidance, compared to individuals with low avoidance. Supporting this theory, recent work among sexual minority men in the US has qualitatively (Batchelder et al., 2021a) and quantitatively (Batchelder et al., 2021b) identified avoidance as playing a role in the relationship between substance use (SU) stigma and HIV appointment attendance. However, no studies have examined avoidant behavior as a moderator of internalized stigma and HIV/SU outcomes in SA, a low-and middle-income country with the highest HIV burden.

To better understand how HIV and alcohol stigmas impact related health behaviors in SA, we examined associations between (a) internalized alcohol stigma and HIV outcomes (i.e., ART adherence, VL suppression), and (b) internalized HIV stigma and alcohol outcomes (i.e., alcohol consumption/related problems). We hypothesized that higher levels of stigma would be associated with worse HIV and alcohol outcomes. In exploratory analyses, we examined (c) the interaction of both stigmas on HIV and alcohol outcomes, and (d) whether avoidance moderated the relationships in aims (a) and (b).

2. Methods

2.1. Recruitment and study procedures

The present study uses baseline data from a randomized clinical trial (Magidson et al., 2020, 2021) and includes participants who met inclusion criteria for problem drinking (N=64) and challenges with ART nonadherence (see Magidson et al., 2020 for details). PWH on ART were screened at an HIV clinic in a high HIV burden, low-resource area (Western Cape Government, 2019) between August 2018 and October 2019 where SU treatment engagement is low despite the availability of a free evidence-based program (Magidson et al., 2019, 2021).

All participants provided written informed consent. At baseline, participants had blood drawn for dried blood spot (DBS) and VL analysis and completed self-report measures of stigma, adherence, and problematic drinking in English or Xhosa. All procedures were approved by ethics committees at the University of Cape Town and City of Cape Town.

2.2. Measures

Predictors – stigma and avoidance.

Internalized alcohol stigma was measured with the Internalized Stigma Subscale of the Substance Use Stigma Mechanisms Scale (SU-SMS; Smith et al., 2016). Internalized HIV stigma was measured with the Internalized HIV Subscale of the HIV Stigma Mechanism Scale (Earnshaw et al., 2013). Avoidance was measured with the Avoidance/Rumination subscale of the Behavioral Activation for Depression Scale (Kanter et al., 2007), which assesses past-week avoidance of general problems and negative emotions. All scales were continuous, with higher scores indicating more stigma/avoidance.

Outcomes – HIV.

ART adherence was assessed biologically with DBS analysis of tenofovir diphosphate (TFV-DP; n=46) for the patients on a tenofovir-based regimen. The remaining 18 participants were on a non-TFV-DP regimen and were excluded from analysis. Adherence was also assessed via self-report with a three-item measure (Wilson et al., 2016) that has been used in similar populations (Phillips et al., 2017). VL was extracted from patients’ medical records or tested when unavailable within three months of baseline. Based on local clinic standards, suppression was defined dichotomously as <400 copies/mL.

Outcomes – alcohol.

Alcohol consumption was assessed biologically using DBS testing of Phosphatidylethanol (PEth), a sensitive and specific measure of alcohol that remains in the blood for approximately 21 days (Bajunirwe et al., 2014; Hahn et al., 2012). Problematic drinking was assessed via self-report with the Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2001), which asks participants about consumption and associated problems (e.g., how often have you failed to do what was normally expected because of drinking) in the past year and lifetime.

All variables were treated continuously with the exception of VL.

2.3. Data Analytic Plan

Linear regressions were conducted for all outcomes except for VL, which was analyzed using logistic regression. Predictors included internalized stigmas, avoidance, and their interactions for moderation analyses. If a significant interaction was identified, the interaction was further probed. Specifically, separate regression lines for one predictor variable and the outcome variable were computed and tested at low (one standard deviation (SD) below the sample’s mean), mean, and high (one SD above sample’s mean) levels of the other predictor variable (Aiken & West, 1991). All analyses were performed with R (R Core Team, 2020). Unadjusted models and an alpha of .05 were used for all analyses.

3. Results

3.1. Participants

Table 1 summarizes demographic and clinical characteristics. All self-report measures in the sample indicated high reliability (Table 1). Self-report adherence and TFV-DP were significantly correlated with each other (r=.33, p=.02), but not with VL suppression (self-report: r=−.04, p=.74; TFV-DP: r=−.01, p=.96). AUDIT and PEth were not significantly correlated (r=.13, p=.31); however PEth and the AUDIT-C—three items of the AUDIT that assess consumption (not consequences) (Morojele et al., 2014)—were significantly correlated (r=.29, p=.02).

Table 1.

Demographic Characteristics and Descriptive Statistics

Variable N M (SD) or N (%) Range α1
Age 64 37.12 (9.30) 21 – 57 --
Women 64 34 (53.1%) -- --
Black African 64 63 (98.4%) -- --
Primary language: isiXhosa 64 64 (100%) -- --
Employed (part- or full-time) 64 15 (23.4%) -- --
Religion
Christian 64 38 (59.4%) -- --
Traditional 64 25 (39.1%) -- --
None 64 1 (1.6%) -- --
Heterosexual 64 64 (100%) -- --
WHO-ASSIST Alcohol2 64 26.25 (6.35) 13 – 37 --
SU-SMS Internalized Subscale 64 2.67 (1.30) 1.00 – 4.67 .95
HIV-SMS Internalized Subscale 64 1.96 (1.12) 1.00 – 5.00 .95
BADS Avoidance/Rumination Subscale 64 29.80 (7.64) 16 – 48 .86
AUDIT3,4 63 19.35 (6.56) 3 – 31 .81
Score 8 – 14 63 8 (13%) --
Score 15 – 19 63 11 (17%) --
Score ≥20 63 40 (63%) --
PEth5 64 570.41 (583.54) 13 – 2494 --
Level ≥50 64 54 (84%) --
Three-item self-reported adherence 64 42.59 (19.33) 0 – 76.67 .90
TFV-DP6 46 1057.28 (511.12) 16 – 2251 --
Suppressed HIV VL7 (n (%)) 64 40 (62.5%) -- --
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NOTE: In analyses, all measures except suppressed VL were measured continuously.

1

Cronbach’s alpha for self-report measures

2

Scores >10 suggest moderate risk, >26 suggest high risk

3

n=1 participant excluded from AUDIT analyses due to not answering all questions.

4

Scores 8 – 14 suggest problematic drinking, scores 15 – 19 suggest harmful drinking; scores ≥20 suggest alcohol dependence

5

PEth ≥50 is clinical cut-off for unhealthy alcohol use

6

TFV-DP levels only available for those on a tenofovir-based ART. There were no significant differences in gender, age, self-report adherence, stigma scores, avoidance, or alcohol outcomes between those on and not on such ARTs.

7

Suppression defined as <400 copies/mL, based on local clinic standards at the time of the study

3.2. Stigmas in Isolation

Increased internalized alcohol stigma was significantly associated with a lower likelihood of VL suppression (OR=1.68, 95%CI[1.11 2.65], b(SE)=−.52(.22), p=.02). There was a non-significant trend showing a negative association between internalized alcohol stigma and TFV-DP levels (b(SE)=−104.75(56.61), t(44)=−1.85, p=.07). Internalized alcohol stigma was not associated with self-reported ART adherence. Internalized HIV stigma was not significantly associated with either alcohol outcome.

3.3. Intersecting Stigmas

The interaction between internalized alcohol and HIV stigmas was not significantly associated with HIV or alcohol outcomes.

3.4. Avoidance as a Moderator

Avoidance did not moderate the relationship between internalized alcohol stigma and HIV outcomes. However, avoidance did moderate the relationship between internalized HIV stigma and AUDIT scores (b(SE)=.24(.09), t(59)=2.64, p=.01; see Figure 1a). At low levels of avoidance, higher HIV stigma was significantly associated with lower AUDIT scores (b(SE)=−1.92(.85), p=.03). At high levels of avoidance, the relationship between HIV stigma and AUDIT scores was non-significant, though the direction of this relationship suggests higher HIV stigma was associated with higher AUDIT scores (b(SE)=1.81(1.23), p=.15). Avoidance did not significantly moderate the relationship between HIV stigma and PEth (b(SE)=12.17(8.24), t(60)=1.48, p=.15). However, the non-significant graphed interaction shows directionality consistent with AUDIT results (Figure 1b).

Figure 1. Significant and non-significant interactions between Avoidance and Internalized HIV Stigma for problem drinking.

Figure 1.

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Figure 1a shows associations between internalized HIV stigma and AUDIT scores estimated at high (1 standard deviation above group’s mean; non-significant), mean (group’s mean), and low (1 standard deviation below group’s mean; significant) levels of avoidance. Figure 1b shows non-significant associations between internalized HIV stigma and PEth level at estimated high, mean, and low levels of avoidance.

4. Discussion

This study contributes to our understanding of the interrelationships between internalized HIV and alcohol stigmas with HIV-and alcohol-related outcomes in a resource-limited, high-burden HIV and alcohol context. Findings suggest that higher internalized alcohol stigma is significantly associated with lower likelihood of VL suppression. Findings also indicate a potential moderating effect of avoidance on the relationship between HIV stigma and problem drinking. Similar to research in the US (Stringer et al., 2019), significant relationships were not identified between an internalized SU stigma and ART adherence. However, unlike recent US studies, avoidance did not play a role in associations between an internalized SU stigma and HIV-related outcomes (Batchelder et al., 2021b). This discrepancy could be due to our small sample size; different measures of stigma (alcohol versus SU), avoidance, and HIV-related outcomes (adherence versus missed appointments); examining avoidance as a moderator versus a mediator; or the different populations examined.

Findings have important implications for behavioral intervention development and adaptation, especially in low-resource, high-burden HIV and alcohol settings like SA. If findings replicate in future studies (i.e., with a larger sample and longitudinal design), results may inform interventions targeting stigma, HIV, and problem drinking. For instance, stigma-reduction efforts may target those with high avoidance, as the deleterious effects of stigma may not operate in the same way for people with lower avoidance. In particular, problem-solving therapy and other behavioral interventions should be considered, given evidence that behavioral approaches may be effective in reducing internalized stigma (Pantelic et al., 2019) and improving avoidance (Myers et al., 2017; Safren et al., 2004) among PWH. Interventions targeting people with lower avoidance may need to focus on shifting factors other than internalized stigma for health behaviors to improve (Vetrova et al., 2022).

Despite implications for patient-level interventions, it is essential to note the onus on stigma reduction should be on the stigmatizing structures, not the stigmatized individuals (del Río-González et al., 2021). Thus, although we focus on internalized stigma as a potentially modifiable target in individual-level interventions, we acknowledge the systematic factors that perpetuate HIV and alcohol stigma, for instance, healthcare providers and organizations (e.g., Regenauer et al., 2020) as well as pervasive community stigma (Sorsdahl et al., 2012), which should be targeted as part of a comprehensive strategy for reducing effects of stigma on health outcomes.

Findings should be interpreted in light of limitations and in the context of intersectionality. Analyses were limited by a small sample size. Results may have been different with a larger sample and other meaningful patterns may have emerged had we been powered to control for confounders such as gender (Sorsdahl et al., 2012). Biomarker-verified ART adherence analyses were further limited by not all participants being on a tenofovir-based regimen. While all participants were PWH, struggling with alcohol, Black African or mixed race, heterosexual, and living in a low-resource setting, other aspects of their identity may differ. Stigma based on other intersecting identities such as gender and religion, together with other factors likely to impact stigma (e.g., discrimination) are important to examine in the future. Finally, it is important to acknowledge that intersectionality itself is not quantitatively testable (del Río-González et al., 2021). While interaction analyses are more in-line with the goal of intersectionality theory than many other statistical approaches, we were neither powered to detect, nor able to measure, all potentially relevant intersecting identities.

4.1. Conclusion

We aimed to examine under-researched associations between internalized HIV and alcohol stigma with HIV and alcohol outcomes among PWH in a resource-limited, high HIV/alcohol burden context, and the potential role of avoidance in moderating these relationships. Despite a small sample, we found a significant association between internalized alcohol stigma and VL, and avoidance significantly moderated the relationship between internalized HIV stigma and problematic drinking. As this is the first study to examine these questions in SA—the country with the highest burden of HIV globally and significant alcohol burden—these preliminary findings provide an important foundation for future clinical research in a resource-limited, high burden context.

Supplementary Material

1

Highlights.

  • HIV and alcohol stigmas were examined in a low-resource, high HIV burden setting

  • High alcohol stigma was associated with lower likelihood of viral load suppression

  • Avoidance moderated the relationship between HIV stigma and alcohol use

  • Findings may inform future intervention efforts for HIV and alcohol stigmas

Acknowledgments

We would like to thank all the participants who made this study possible. We would also like to thank the sources that funded the grant, along with the sources that funded the authors’ time. Finally, we would like to thank the full Project Khanya team, including but not limited to, Nonceba Ciya, Neliswa Kotelo, Sybil Majokweni, Sibabalwe Ndamase, and Alexandra Rose. All views expressed are those of the authors and not necessarily those of the funders.

Role of funding sources

This study is funded by the National Institute on Drug Abuse (NIDA) grant K23DA041901, awarded to Dr. Jessica Magidson. Dr. Magidson and Myers’ time was additionally supported by NIDA grant R21DA053212 (Magidson/Myers) and National Institute of Mental Health (NIMH) grant R34MH122268 (Magidson/Myers). The sponsoring agencies had no role in the study design, analysis, interpretation of the results, manuscript writing, or decision to submit the manuscript for publication.

Footnotes

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Conflict of Interest

No conflicts declared

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