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Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis

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Abstract

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

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Acknowledgements

Work by Kristi L Stringer was supported through an institutional training grant from the National Institute of Drug Abuse (R25DA037190). Andrea Norcini Pala is supported by the following National Institute for Mental Health (NIMH) grants: (K01MH125724 and R01MH131177). The data were collected by the Women’s Interagency HIV Study (WIHS), now the MACS/WIHS Combined Cohort Study (MWCCS). This study was funded by a grant from the National Institutes of Health (NIH) R03DA052180. Contents of this publication are solely the responsibility of the authors and do not represent the official views of NIH. MWCCS (Principal Investigators): Atlanta CRS (Ighovwerha Ofotokun, Anandi Sheth, Gina Wingood), U01-HL146241; Data Analysis/Coordination Center (Gypsyamber D’Souza, Stephen Gange, Elizabeth Topper), U01-HL146193; Northern California CRS (Bradley Aouizerat, Jennifer Price, Phyllis Tien), U01-HL146242; UAB-MS CRS (Mirjam-Colette Kempf, Jodie Dionne-Odom, Deborah Konkle-Parker), U01-HL146192. The MWCCS is funded primarily by the National Heart, Lung, and Blood Institute (NHLBI), with additional co-funding from the Eunice Kennedy Shriver National Institute Of Child Health & Human Development (NICHD), National Institute On Aging (NIA), National Institute Of Dental & Craniofacial Research (NIDCR), National Institute Of Allergy And Infectious Diseases (NIAID), National Institute Of Neurological Disorders And Stroke (NINDS), National Institute Of Mental Health (NIMH), National Institute On Drug Abuse (NIDA), National Institute Of Nursing Research (NINR), National Cancer Institute (NCI), National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Deafness and Other Communication Disorders (NIDCD), National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institute on Minority Health and Health Disparities (NIMHD), and in coordination and alignment with the research priorities of the National Institutes of Health, Office of AIDS Research (OAR). MWCCS data collection is also supported by UL1-TR000004 (UCSF CTSA), UL1-TR003098 (JHU ICTR), UL1-TR001881 (UCLA CTSI), P30-AI-050409 (Atlanta CFAR), P30-AI-073961 (Miami CFAR), P30-AI-050410 (UNC CFAR), P30-AI-027767 (UAB CFAR), and P30-MH-116867 (Miami CHARM). We thank participants and the staff at the research sites.

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Author notes

  1. Kristi Lynn Stringer and Andrea Norcini Pala have equally contributed to this work.

Authors and Affiliations

  1. Department of Health and Human Performance, Community and Public Health, Middle Tennessee State University, Murfreesboro, TN, 37132, USA

    Kristi Lynn Stringer

  2. Columbia School of Social Work, Columbia University, New York, NY, USA

    Andrea Norcini Pala

  3. Department of Epidemiology, Colleges of Public Health and Health Professions and Medicine, University of Florida, Gainesville, FL, USA

    Robert L. Cook

  4. Schools of Nursing, Public Health, and Medicine, University of Alabama at Birmingham, Birmingham, AL, USA

    Mirjam-Colette Kempf

  5. Schools of Nursing, Medicine and Population Health, University of Mississippi Medical Center, Oxford, MS, USA

    Deborah Konkle-Parker

  6. Department of Community Health Sciences, School of Public Health, State University of New York Downstate Health Sciences University, Brooklyn, NY, USA

    Tracey E. Wilson

  7. Department of Medicine, Department of Veteran Affairs Medical Center, University of California, San Francisco and Medical Service, San Francisco, CA, USA

    Phyllis C. Tien

  8. Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York City, NY, USA

    Gina Wingood

  9. Division of Prevention Science, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA

    Torsten B. Neilands & Mallory O. Johnson

  10. Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, USA

    Carmen H. Logie

  11. Women’s College Research Institute, Women’s College Hospital, Toronto, ON, USA

    Carmen H. Logie

  12. Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA

    Sheri D. Weiser

  13. Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA

    Janet M. Turan

  14. Department of Public Health, School of Medicine, Koc University, Istanbul, Turkey

    Janet M. Turan

  15. College of Social Sciences and Humanities, Psychology, Koc University, Istanbul, Turkey

    Bulent Turan

  16. Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA

    Bulent Turan

Authors
  1. Kristi Lynn Stringer
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  2. Andrea Norcini Pala
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  3. Robert L. Cook
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  4. Mirjam-Colette Kempf
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  5. Deborah Konkle-Parker
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  6. Tracey E. Wilson
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  7. Phyllis C. Tien
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  8. Gina Wingood
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  9. Torsten B. Neilands
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  10. Mallory O. Johnson
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  11. Carmen H. Logie
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  12. Sheri D. Weiser
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  13. Janet M. Turan
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  14. Bulent Turan
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Contributions

KLS: Conceptualization, Visualization Writing—Original Draft Preparation, Writing—Review and Editing; ANP: Conceptualization, Formal Analysis, Methodology, Writing—Original Draft Preparation, Visualization; RLC: Funding Acquisition, Investigation, Writing—Review and Editing; M-CK: Funding Acquisition, Investigation, Writing—Review and Editing; DK-P: Funding Acquisition, Investigation, Writing—Review and Editing; TEW: Funding Acquisition, Investigation, Writing—Review and Editing; PCT: Funding Acquisition, Investigation, Writing—Review and Editing; GW: Funding Acquisition, Investigation, Writing—Review and Editing, TBN: Funding Acquisition, Investigation, Writing—Review and Editing, MOJ: Funding Acquisition, Investigation, Writing—Review and Editing, CHL: Funding Acquisition, Investigation, Writing—Review and Editing; SDW: Funding Acquisition, Investigation, Writing—Review and Editing; JMT: Funding Acquisition, Investigation, Writing—Review and Editing, Supervision; BT: Data Curation, Conceptualization, Supervision, Funding Acquisition, Investigation, Project Administration, Methodology.

Corresponding author

Correspondence to Kristi Lynn Stringer.

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Conflict of interest

Kristi Lynn Stringer, Andrea Norcini Pala, Robert L Cook, Mirjam-Colette Kempf, Deborah Konkle-Parker, Tracey E. Wilson, Phyllis C. Tien, Gina Wingood, Torsten B. Neilands, Mallory O. Johnson, Carmen H. Logie, Sheri D. Weiser, Janet M. Turan, and Bulent Turan declare that they have no conflict of interest.

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Stringer, K.L., Norcini Pala, A., Cook, R.L. et al. Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis. AIDS Behav (2024). https://doi.org/10.1007/s10461-024-04282-6

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