Seth Charles Kalichman

HIV stigma remains a stubborn barrier to antiretroviral therapy (ART) adherence and interventions to improve ART adherence are not well-informed by stigma mechanisms. Stigma theories posit that past stigma experiences sensitize individuals to anticipate future stigma. Furthermore, the impact of anticipated stigma on ART adherence may be explained by stigma-induced distress and behaviors to avoid future stigma. Grounded in contemporary stigma theories, the current study examined stigma-induced distress and stigma avoidance behaviors as serial mediators in the association between anticipated stigma and ART adherence. People living with HIV and receiving ART ( N = 695) were enrolled in a 1-month prospective study. We confirmed our main hypothesis that stigma-induced distress was associated with stigma-avoidance behaviors, and that distress and avoidance serially mediated the association between anticipated stigma and ART adherence. We conclude that stigma-induced distress and stigma-avoidance strategies are amenable targets for behavioral interventions to reduce the impacts of stigma on adherence.

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HIV-related stigma experiences impede healthcare engagement and adversely impact people living with HIV. However, the mechanisms that account for the association between stigma and poor health are not fully known. Grounded in contemporary theories of stigma and health, we conducted a 16-month prospective cohort study of 435 younger people living with HIV (ages 18–36), with 352 (81%) retained over 16 months. We tested two primary hypotheses: (a) in cross-sectional analyses, perceived social support would mediate for the association between HIV stigma experiences and missing recent HIV care appointments; and (b) in prospective analyses, the association between stigma and HIV viral load would be serially mediated by perceived social support and missed care appointments. We tested these associations for both past stigma experiences (e.g., enacted stigma) and expectancies for future stigma (e.g., anticipated stigma). Results confirmed both hypotheses: perceived social support mediated the association between both enacted and anticipated stigma and recently missed care appointments; and the association between both enacted and anticipated stigma and viral load were serially mediated by perceived social support and missed care appointments. These findings affirm that diminished social support may explain the association between HIV-related stigma and poor health outcomes in younger people living with HIV. Results are discussed in the context of interventions designed to mitigate the adverse effects of stigma by building sustainable support networks among younger people living with HIV.