Secondary Logo

Journal Logo

Editorial

Effects of an intervention on internalized HIV-related stigma for individuals newly entering HIV care

Yigit, Ibrahima; Modi, Riddhi A.b; Weiser, Sheri D.c; Johnson, Mallory O.d; Mugavero, Michael J.e; Turan, Janet M.f; Turan, Bulenta

Author Information
doi: 10.1097/QAD.0000000000002566
  • Open

Abstract

Introduction

HIV-related stigma is a complex social process in which people living with HIV (PLWH) experience prejudice, devaluation, discrimination, rejection, and other negative attitudes because of the fact that they are living with HIV [1–4]. Multiple dimensions of HIV-related stigma have been identified, including anticipated, experienced, perceived community, and internalized stigma [2,4–7]. Internalized HIV-related stigma refers to accepting and adopting negative evaluations held in society about PLWH and applying these evaluations to oneself [2,8–11]. A significant body of research suggests that internalized HIV-related stigma is associated with poor engagement in HIV treatment and care, sub-optimal medication adherence, missed clinic visits, and lower access to medical care [12–15]. In addition to these adverse health behaviors and outcomes, internalized HIV-related stigma has been linked with affective, cognitive, and mental health outcomes, such as depression [5,8,16–21], anxiety [22,23], hopelessness [22], low medication adherence self-efficacy [24], dysfunctional coping styles (i.e. self-blame, avoidance, denial) [5,25], and low quality of life [22,26–29].

Theoretical and empirical work suggests that internalized HIV stigma has a stronger association with HIV treatment behaviors and outcomes compared with other dimensions of HIV-related stigma (i.e. anticipated, perceived community, and enacted) [3,8]. Furthermore, associations between other dimensions of stigma and outcomes may work through the pathway of increased internalized stigma [5,6,10,30,31]. Given the importance of sustained and consistent treatment adherence to achieve viral suppression and to prevent onward transmission of HIV [32,33], interventions aiming to reduce internalized HIV-related stigma are needed.

Many stigma interventions have focused on perceived or enacted stigma as the outcome [34–37]. Although some of these interventions resulted in reductions in HIV-related stigma [34,38–42], some interventions did not seem to decrease HIV-related stigma [35,43]. Several interventions have been developed that specifically target the internalized HIV-related stigma that PLWH feel [44–46]. For instance, a study with women living with HIV suggested that intensive cognitive behavioral therapy addressing themes, such as feelings of powerlessness, guilt, anger, and reactions from others decreases the level of internalized HIV-related stigma [47]. However, a recent review found inconsistent evidence, on average, on the effects of interventions on internalized stigma [48]. This is perhaps not surprising as interventions vary considerably in their content, format, and targets. This review highlighted that psycho-educational interventions focusing on building skills and social support networks, managing negative feelings, developing strategies for coping with stigma, and education on medical aspects of HIV are more effective in reducing internalized HIV stigma compared with other approaches. A second review of interventions reported reductions in internalized HIV stigma across studies, and suggested that interventions including both structural (e.g. social empowerment, ART roll-out) and individual (e.g. mental health, stigma education) level components are more effective compared with only individual-level interventions [35]. Moreover, among individual-level interventions, only cognitive behavioral therapy was found to have an effect on internalized stigma -- other strategies did not seem to be effective in reducing internalized stigma.

Thus, although a variety of interventions are being evaluated and some identified as beneficial [35,36], the effects of such interventions on internalized HIV-related stigma have yet to be conclusively demonstrated and the evidence on how these interventions work to reduce stigma are not well developed [36,49]. There is an urgent need for interventions with multidimensional components (e.g. psychosocial support, health education, structural factors, economic empowerment) to address internalized HIV-related stigma. This need is particularly pressing for those who are newly initiating HIV medical care and treatment [50].

Many new-to-care patients have limited experience navigating the healthcare system and may not be prepared for a long-term commitment to taking prescribed medications [51–53]. The first year for individuals new to care is a critical and vulnerable time for adjusting to a life-changing diagnosis and associated negative physical and psychological health implications [54]. Specifically, PLWH are expected to attend clinic visits and start life-long ART, which are essential to achieving viral load suppression and optimal health outcomes [51,54,55]. Research suggests that newly diagnosed PLWH often delay seeking HIV care and initiating ART and subsequently miss clinic visits, which in turn lead to delayed viral load suppression, greater cumulative viral load burden, and increased mortality and morbidity [18,54,56–59]. In addition, immediately after HIV diagnosis, the level of HIV-related stigma, especially internalized stigma experienced by PLWH, is often high [60–62], potentially resulting in suboptimal care engagement and ART adherence behaviors. As such, the period when PLWH initiate care is critical and understanding and addressing adjustment to living with HIV and internalized HIV-related stigma early with new-to-care PLWH is crucial in terms of improving treatment outcomes.

The ‘integrating ENGagement and Adherence Goals upon Entry’ (iENGAGE) intervention was developed to facilitate adjustment to living with HIV and thereby to improve engagement in and adherence to HIV treatment and care through different mechanisms among individuals initiating HIV care [50]. The goals of the intervention include helping patients to adjust to living with HIV, to deal with ensuing negative emotions, to normalize the experience of living with HIV, to set goals, and to acquire problem-solving skills, potentially leading to reduced internalized HIV-related stigma and self-depreciating emotions. The intervention also aims to help to actively identify and combat self-identified barriers to treatment adherence, including retention in care and ART adherence [63,64]. Thus, for patients for whom stigma is identified as a barrier, the intervention has an explicit focus on stigma. In this article, we examine the effects of the iENGAGE intervention on internalized HIV stigma.

Moreover, there is a lack of understanding of mental health and psychosocial factors that may moderate the effects of psychosocial interventions on internalized HIV-related stigma. Many PLWH who experience HIV-related stigma also report depressive symptoms and develop maladaptive coping skills [5,25,31,65,66], and interventions usually target all of these factors [48]. Thus, it is important to better understand how these factors interact with a stigma-reducing intervention in order to determine which sub-populations are more vulnerable and should be prioritized. Within this context, one study suggested significant moderation effects of depressive symptoms on the effects of an antistigma intervention (including education, contact with PLWH, counseling, and improving coping skills) on HIV-related stigma among African American women living with HIV [67].

The present analyses have two primary aims: to evaluate the effects of the iENGAGE intervention on internalized HIV-related stigma by comparing changes in stigma in the two arms of the randomized controlled trial (RCT) at the conclusion of the 48-week intervention in a sample of PLWH who were newly entering HIV care and to examine whether the effect of the intervention on change in internalized HIV-related stigma is moderated by depressive symptoms and coping styles (i.e. behavioral disengagement and self-blame; two coping styles found important in coping with HIV in previous research [5,31,66], and may theoretically affect the degree to which the intervention is effective).

Methods

Trial design

The iENGAGE randomized controlled trial allocated eligible, new to care PLWH to the intervention arm or standard of care control arm (1 : 1) using permuted block randomization without any modifications to enrollment or study procedures following commencement of the trial.

Participants

Participants were 18 years and older with documented HIV infection, initiating HIV care at one of the four participating academically affiliated HIV clinical sites: the University of Alabama at Birmingham (UAB), the University of North Carolina at Chapel Hill (UNC), Johns Hopkins University (JHU), and the University of Washington at Seattle (UW). Those who were English speaking, not planning to move in the next 12 months, and able and willing to provide informed consent were enrolled in the study within 14 days of their initial HIV primary care appointment [50].

The intervention

Study arm (intervention vs. control)

The iENGAGE intervention arm participants received four face-to-face sessions (0–2, 2–12, 12–24, and 24–48 weeks after randomization) at the HIV clinic by a study counselor. Additionally, participants received interim enhanced personal contact calls, visit reminder calls, and missed visit calls during the study period. The iENGAGE intervention was tailored individually to improve participant information, motivation, and behavioral skills (IMB), using an assessment tool mapped to content domains to inform delivery of structured intervention content, by trained counselors, grounded in principles of motivational interviewing. The details of this theory-based intervention can be found elsewhere [50]. The first face-to-face intervention session focused on introducing the participant to the iENGAGE intervention, providing basic education on HIV and HIV care, including importance of attending all medical appointments, and an opportunity to process HIV diagnosis and develop trust and rapport with the iENGAGE counsellor. All intervention participants completed an iENGAGE screener and developed a goal of retaining in care. The follow-up sessions focused on maintaining a positive approach and participating in skills building modules with the counsellors. Another goal was to identify and combat barriers to treatment adherence individually for each participant, including HIV-related stigma (For 21.5% of the participants, stigma was identified as a barrier to treatment adherence). Each session included a review of goals from the prior session and adjustment to living with HIV. In addition, counsellors addressed questions raised by participants. At the final intervention session, methods for maintaining intervention gains in the future were discussed. The control arm participants received standard of care at each participating clinic site [68]. Standard of care included various strategies to support antiretroviral therapy (ART) adherence and retention in care (e.g. use of illustrative materials to deliver information and encouraging participants to store spare doses in particular places). A self-administered standard-of-care measure was completed by 75 healthcare providers across the four study sites to determine engagement in care and ART adherence resources available contemporaneously to the iENGAGE trial. On balance, few resources were utilized to systematically monitor care engagement and adherence and provide this information to providers, whereas nearly all providers reported counseling PLWH on ART adherence and the associated favorable health outcomes [50,68].

The iENGAGE interventionists at each site were provided training on the intervention developed by behavioral scientists on the study team. This training also included a background in providing case management and counseling services. The training consisted of 2-day in-person workshops at UAB and UW, subsequent conference calls every week during the initial year, and then twice monthly, and then monthly calls. Furthermore, a periodic review of recorded interviews was implemented and feedback was provided by the study trainer. During the second year, an in-person booster training workshop was also conducted with feedback. Additionally, for new counselors who joined the study team later, phone trainings were provided. All counselors had a college education –associates or bachelor's degree.

Measures

Baseline and 48-week final assessments as secondary outcomes were conducted using a computer-administered self-interview (CASI).

Internalized HIV stigma was assessed with the revised HIV Stigma Scale [69] using a four-point Likert-like scale (seven items) (e.g. ‘Having HIV/AIDS makes me feel that I’m a bad person’). The higher the composite scores, the higher the internalized stigma.

Depressive symptoms were assessed with the Patient Health Questionnaire depression scale-PHQ-8 [70]. PHQ-8 includes eight items and uses a four-point Likert-like scale (‘not at all’= 0 to ‘nearly every day’= 3) and scores range from 0 to 24.

Coping styles -- behavioral disengagement and self-blame -- were assessed with items from the Brief COPE Scale [71] with a total of four items using a four-point Likert scale. A mean score was calculated for each coping style.

Sample size and power

Overall, 941 participants were screened, of which 372 participants were enrolled across four sites. A sample size of 371 was used for analysis, as one participant was deemed not new-to-care after being randomized to the intervention arm and was withdrawn. The study was originally powered at 80% to detect an absolute difference of 15% between arms for the primary outcome, viral suppression at 48 weeks [72]. As for the secondary outcome (effect of the intervention on changes in stigma), the sample size of 400 (200 per arm) was calculated to detect an effect size of Cohen's d = 0.3 or larger with 80% power in terms of the scores from baseline to 48 weeks between the intervention and control arms [50,72]. We used a two-sided two-sample independent sample t-test and an alpha of 0.05. Final survey data and 48-week viral load values were available for 314 participants (85% of iENGAGE sample), including 155 intervention (84%) and 159 control (85%) participants, indicating robust study retention.

Assignment method and blinding (masking)

A permuted block randomization method (1 : 1 ratio) with random block sizes of 2, 4, or 6 was used for assignment to the intervention or the control arm. Randomization was stratified by site. iENGAGE research staff and patients were blinded to treatment arm assignment until after the baseline assessment was completed. After completion of baseline survey, study personnel and patients were unmasked to study arm assignment to conduct intervention sessions with intervention arm participants. This process resulted in 185 participants in the intervention arm and 186 participants in the control arm (see Fig. 1).

Fig. 1
Fig. 1:
Participant flow diagram.

Statistical analyses

First, we examined differences between the intervention and the control arms in terms of race, sex, insurance status, site, and age using chi-squared and t-tests. Then, a repeated measures ANOVA was used to evaluate the effects of time (baseline vs. follow-up; a within-subject variable) and study arm (control vs. intervention; a between-subject variable) on internalized HIV stigma. Next, we calculated a score for the amount of decrease in internalized HIV stigma for each participant by subtracting follow-up stigma from baseline stigma and examined whether depressive symptoms and coping styles (behavioral disengagement, self-blame) moderate the effect of the intervention on decrease in internalized HIV stigma. For this, we conducted a series of moderation analyses using the PROCESS macro for SPSS [73]. In moderation analyses, we used baseline scores of depression and coping styles. In case of significant interaction effects, simple slopes were examined at one standard deviation above and below (±1SD) the mean of each moderator variable. For all moderation analyses, unstandardized coefficients were reported.

Results

As anticipated because of randomization, the intervention and control arms were similar in terms of race, sex, insurance status, site, and age, with no statistically significant differences (see Table 1). Repeated measures ANOVA revealed a significant main effect of time, F (1, 298) = 10.10, P = 0.002, n2p = 0.03, indicating that internalized HIV stigma at follow-up (M = 2.17, SD = 0.73) was significantly lower than internalized HIV stigma at baseline (M = 2.30, SD = 0.75, P = 0.002). No significant main effect was found for study arm on average, F (1, 298) = 0.18, P = .674, n2p = .00.

Table 1
Table 1:
Race, sex, insurance status, site, and age by study arm.

Importantly, the interaction between time and study arm was significant, F (1, 298) = 5.06, P = .025, n2p = 0.02. Post hoc comparisons indicated that in the intervention arm, internalized HIV stigma at follow-up (M = 2.11, SD = 0.68) was significantly lower than at baseline (M = 2.32, SD = 0.75, P = 0.000), whereas in the control arm, no significant difference between baseline and follow-up scores of internalized HIV stigma were detected (M = 2.27, SD = 0.75; M = 2.23, SD = 0.77, P = 0.514, respectively) (Fig. 2).

Fig. 2
Fig. 2:
Effect of study arm on in internalized HIV stigma.

Next, we tested whether depressive symptoms moderate the effect of the intervention on the observed decrease in internalized HIV stigma. The main effect of study arm on decrease in internalized HIV stigma was significant (B = 0.17, SE = 0.08, t = 2.25, P = 0.025). However, the main effect of depression on decrease in internalized HIV stigma was not significant (B = 0.01, SE = 0.01, t = 1.44, P = 0.149). Importantly, the effect of study arm on decrease in internalized HIV stigma was significantly moderated by depressive symptoms (interaction effect; B = 0.03, SE = 0.01, t = 2.05, P = 0.040). As shown in Fig. 3, the effect of study arm on decrease in internalized HIV stigma was significant at 1 SD above the mean for depression (high level; B = 0.33, SE = 0.11, t = 2.89, P = .004), but not at 1SD below the mean for depression (low level; B = 0.01, SE = 0.10, t = 0.14, P = 0.887).

Fig. 3
Fig. 3:
Interaction of depressive symptoms with study arm on decrease in internalized HIV stigma.

Then we tested whether self-blame and behavioral disengagement as coping styles also moderate the effect of the intervention on decrease in internalized HIV stigma in two separate moderation analyses. For the moderation of behavioral disengagement, the main effect of study arm on decrease in internalized HIV stigma was not significant (B = 0.15, SE = 0.08, t = 1.84, P = 0.067). The main effect of behavioral disengagement on decrease in internalized HIV stigma was significant (B = 0.07, SE = 0.03, t = 2.35, P = 0.019). However, the effect of study arm on decrease in internalized HIV stigma was not significantly moderated by behavioral disengagement (interaction effect; B = 0.09, SE = 0.06, t = 1.52, P = 0.128). As for the moderation of self-blame, the main effect of study arm on decrease in internalized HIV stigma was significant (B = 0.15, SE = 0.07, t = 2.10, P = 0.036). The main effect of self-blame on decrease in internalized HIV stigma was also significant (B = 0.06, SE = 0.02, t = 3.79, P = 0.000). Importantly, the effect of study arm on decrease in internalized HIV stigma was significantly moderated by self-blame (interaction effect; B = 0.08, SE = 0.03, t = 2.30, P = .022). As shown in Fig. 4, the effect of study arm on decrease in internalized HIV stigma was significant at 1SD above the mean for self-blame (high level; B = 0.33, SE = 0.10, t = 3.18, P = 0.001), but not at 1SD below the mean for self-blame (low level; B = −0.02, SE = 0.11, t = −0.19, P = 0.845).

Fig. 4
Fig. 4:
Interaction of self-blame with study arm on decrease in internalized HIV stigma.

Discussion

The first year following entry to HIV care is an overwhelming time for many PLWH, posing challenges to early treatment adherence and achieving desired clinical outcomes, including viral suppression. Existing studies of stigma-reduction interventions have mainly focused on PLWH who have been in HIV care for many years. The present study examined the effectiveness of the iENGAGE intervention to reduce internalized HIV-related stigma in a sample of PLWH who were newly initiating HIV care, and results suggest that the iENGAGE intervention is effective in reducing internalized HIV-related stigma. This is an important finding, as internalized HIV-related stigma over time negatively affects retention in HIV care, medication adherence, and viral suppression [15,65,74]. In addition to addressing stigma, the iENGAGE intervention includes a variety of modules that facilitate information, motivation, and behavioral skills for adherence to care and ART, focusing on adjustment, problem solving, affect management, and communication. Thus, our findings support the notion that multifaceted and multiphase approaches incorporating psychosocial skill-building can reduce internalized HIV-related stigma. Future research should examine which of these ingredients of the intervention is most important for which sub-populations. Furthermore, research focusing on the effects of linkage to HIV care and ART initiation on internalized HIV-related stigma yielded inconsistent results [75]. Our findings did not support the hypothesis that without a supportive intervention (i.e. in the control group that received standard of care), linkage to HIV care leads to a reduction in internalized HIV stigma. However, if linkage to care is combined with a supportive intervention, internalized HIV stigma does seem to decrease.

This study also advances our knowledge of stigma interventions by examining the moderating effects of depressive symptoms and coping styles in the association between the intervention (control vs. intervention arms) and internalized HIV-related stigma. The results suggest that the intervention has stronger effects for those who have higher levels of depressive symptoms or who use self-blame as coping mechanisms upon HIV medical care initiation. In other words, the higher the level of depressive symptoms and self-blame coping at baseline, the higher the benefit of the iENGAGE intervention in reducing internalized HIV-related stigma over the first year in medical care. This finding is in line with a recent study suggesting that individuals initiating HIV care with posttraumatic stress disorder or depressive symptoms benefit more from a stigma-reduction intervention, resulting in greater improvement in engagement in care [67]. Thus, it appears that these interventions may have greater benefit for those who have multiple psychosocial challenges. On the basis of these data, future interventions may specifically focus on individuals with higher levels of depressive symptoms and who use maladaptive coping strategies. Further research should also focus on the role of other potential moderators of the association between intervention and internalized stigma. It is also possible that associations among internalized HIV-related stigma, depression, and coping styles are bidirectional.

This study had several limitations. Participants were all patients at well resourced HIV clinics affiliated with major academic health centers. Generalizability to other settings, as well as to other geographical locations, remains an open question. Furthermore, the long-term effects of the iENGAGE intervention need to be examined. In addition, the outcome assessment of internalized HIV stigma was based on self-report and may be subject to biases. However, this measure of internalized HIV stigma has been used extensively in previous research, which strongly supports its construct validity [1,15,24]. Finally, this study did not include an attention control condition, which might have affected our conclusions [76].

Despite these limitations, the findings from this study have important implications for the field of stigma intervention research and provide crucial information for policy and programs aiming to improve outcomes for PLWH, particularly during the vulnerable time following diagnosis and HIV care entry. Knowledge about the effect of the iENGAGE intervention on internalized stigma and the moderating mechanisms for this effect can be used to tailor and strengthen interventions to reduce internalized stigma and thereby to maximize benefits for early retention in care and health among PLWH who are new to care, particularly those with higher depressive symptoms and those engaging in self-blame coping.

Acknowledgements

This work was supported by the National Institutes of Allergy and Infectious Diseases (NIAID) grant numbers 5R01AI103661-05 and 3R01AI103661-03S1, ClinicalTrials.gov NCT01900236. This research was also supported by the University of Alabama at Birmingham (UAB) Center for AIDS Research CFAR, an NIH-funded program (P30 AI027767) that was made possible by the following institutes: NIAID, NCI, NICHD, NHLBI, NIDA, NIA, NIDDK, NIGMS, and OAR.

Conflicts of interest

M. J. M. has received grant support (to the University of Alabama at Birmingham) from Merck Foundation and consulting fees from Gilead Sciences. The remaining authors declare no conflict of interest.

References

1. Helms CB, Turan JM, Atkins G, Kempf M, Clay OJ, Raper JL, et al. Interpersonal mechanisms contributing to the association between HIV-related internalized stigma and medication adherence. AIDS Behav 2017; 21:238–247.
2. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS Behav 2009; 13:1160–1177.
3. Turan B, Hatcher AM, Weiser SD, Johnson MO, Rice WS, Turan JM. Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. Am J Public Health 2017; 107:863–869.
4. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol 2001; 27:363–385.
5. Turan B, Budhwani H, Fazeli PL, Browning WR, Raper JL, Mugavero MJ, Turan JM. How does stigma affect people living with HIV? The mediating roles of internalized and anticipated HIV stigma in the effects of perceived community stigma on health and psychosocial outcomes. AIDS Behav 2017; 21:283–291.
6. Kay ES, Rice WS, Crockett KB, Atkins GC, Batey DS, Turan B. Experienced HIV-related stigma in healthcare and community settings: mediated associations with psychosocial and health outcomes. J Acquir Immune Defic Syndr 2018; 77:257–263.
7. Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser SD, Bangsberg DR, Tsai AC. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc 2013; 16: (3 Suppl 2): 18640.
8. Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV stigma mechanisms and well being among PLWH: a test of the HIV stigma framework. AIDS Behav 2013; 17:1785–1795.
9. Brouard P. A closer look: the internalization of stigma related to HIV. In: (USAID) USAfID; 2006.
10. Turan B, Crockett KB, Buyukcan-Tetik A, Kempf M-C, Konkle-Parker D, Wilson TE, et al. Buffering internalization of HIV Stigma: implications for treatment adherence and depression. J Acquir Immune Defic Syndr 2019; 80:284–291.
11. Kalichman SC. The harms of internalized AIDS stigma: a comment on Tsai et al. Ann Behav Med 2013; 46:256–257.
12. Sweeney S, Vanable P. The association of HIV-related stigma to HIV medication adherence: a systematic review and synthesis of the literature. AIDS Behav 2016; 20:29–50.
13. Sayles JN, Wong MD, Kinsler JJ, Martins D, Cunningham WE. The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS. J Gen Intern Med 2009; 24:1101–1108.
14. Rueda S, Mitra S, Chen S, Gogolishvili D, Globerman J, Chambers L, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses. BMJ Open 2016; 6:e011453.
15. Rice WS, Crockett KB, Mugavero MJ, Raper JL, Atkins GC, Turan B. Association between internalized HIV-related stigma and HIV care visit adherence. J Acquir Immune Defic Syndr 2017; 76:482–487.
16. Turan B, Smith W, Cohen MH, Wilson TE, Adimora AA, Merenstein D, et al. Mechanisms for the negative effects of internalized HIV-related stigma on antiretroviral therapy adherence in women: the mediating roles of social isolation and depression. J Acquir Immune Defic Syndr 2016; 72:198–205.
17. Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med 2007; 64:1823–1831.
18. Ulett KB, Willig JH, Lin HY, Routman JS, Abroms S, Allison J, et al. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS 2009; 23:41–49.
19. Vyavaharkar M, Moneyham L, Corwin S, Saunders R, Annang L, Tavakoli A. Relationships between stigma, social support, and depression in HIV-infected African American women living in the rural Southeastern United States. J Assoc Nurses AIDS Care 2010; 21:144–152.
20. Tsai AC, Bangsberg DR, Frongillo EA, Hunt PW, Muzoora C, Martin JN, Weiser SD. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Soc Sci Med 2012; 74:2012–2019.
21. Kalichman SCSL, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care 2009; 21:87–93.
22. Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav 2002; 6:309–319.
23. Herek GM, Saha S, Burack J. Stigma and psychological distress in people with HIV/AIDS. Basic Appl Soc Psychol 2013; 35:41–54.
24. Seghatol-Eslami VC, Dark HE, Raper JL, Mugavero MJ, Turan JM, Turan B. Interpersonal and intrapersonal factors as parallel independent mediators in the association between internalized HIV stigma and ART adherence. J Acquir Immune Defic Syndr 2017; 74:e18–e22.
25. Lyimo RA, Stutterheim SE, Hospers HJ, de Glee T, van der Ven A, de Bruin M. Stigma disclosure, coping, and medication adherence among people living with HIV/AIDS in Northern Tanzania. AIDS Patient Care STDS 2014; 28:98–105.
26. Slater LZ, Moneyham L, Vance DE, Raper JL, Mugavero MJ, Childs G. The multiple stigma experience and quality of life in older gay men with HIV. J Assoc Nurses AIDS Care 2015; 26:24–35.
27. Vyavaharkar M, Murdaugh ML, Tavakoli CA. Factors associated with quality of life among rural women with HIV disease. AIDS Behav 2012; 16:295–303.
28. Fuster-Ruizdeapodaca MJMF, Holgado FP, Mayordomo S. Enacted and internalized stigma and quality of life among people with HIV: the role of group identity. Qual Life Res 2014; 23:1967–1975.
29. Subramanian T, Gupte MD, Dorairaj VS, Periannan V, Mathai AK. Psycho-social impact and quality of life of people living with HIV/AIDS in South India. AIDS Care 2009; 21:473–481.
30. Turan B, Rogers AJ, Rice WS, Atkins GC, Cohen MH, Wilson TE, et al. Association between perceived discrimination in healthcare settings and HIV medication adherence: mediating psychosocial mechanisms. AIDS Behav 2017; 21:3431–3439.
31. Fazeli PL, Turan JM, Budhwani H, Smith W, Raper JL, Mugavero MJ, Turan B. Moment-to-moment within-person associations between acts of discrimination and internalized stigma in people living with HIV: an experience sampling study. Stigma Health 2017; 2:216–228.
32. Mugavero MJ, Amico KR, Horn T, Thompson MA. The state of engagement in HIV care in the United States: from cascade to continuum to control. Clin Infect Dis 2013; 57:1164–1171.
33. Bangsberg DR, Perry S, Charlebois ED, Clark RA, Roberston M, Zolopa AR, et al. Nonadherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS 2001; 15:1181–1183.
34. Bhatta DN, Liabsuetrakul T. Efficacy of a social self-value empowerment intervention to improve quality of life of HIV infected people receiving antiretroviral treatment in Nepal: a randomized controlled trial. AIDS Behav 2017; 21:1620–1631.
35. Ma PHXCZ, Loke AY. Internalized stigma reduction interventions for people living with HIV/AIDS and their families: a systematic review. AIDS Behav 2019; 23:707–741.
36. Siegfried NBR. Systematic review on the evidence-base for eliminating stigma and discrimination in healthcare settings. 2017.
37. Stangl AL, Lloyd JK, Brady LM, Holland CE, Baral S. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come?. J Int AIDS Soc 2013; 16: (3 Suppl 2): 18734.
38. Echenique M, Saint-Jean IL, Avellaneda G, Sanchez-Martinez VB, Eisdorfer MC. Impact of a secondary prevention intervention among HIV-positive older women. AIDS Care 2013; 25:443–446.
39. Skinta MD, Lezama M, Wells G, Dilley JW. Acceptance and compassion-based group therapy to reduce HIV stigma. Cogn Behav Pract 2015; 22:481–490.
40. Hosek SGLD, Harper GW, Telander K. Evaluating the acceptability and feasibility of Project ACCEPT: an intervention for youth newly diagnosed with HIV. AIDS Educ Prev 2011; 23:128–144.
41. Uys LCM, Kohi T, Greeff M, Naidoo J, Makoae L, et al. Evaluation of a health setting-based stigma intervention in five African countries. AIDS Patient Care STDS 2009; 23:1059–1066.
42. Kaai S, Bullock S, Sarna A, Chersich M, Luchters S, Geibel S, et al. Perceived stigma among patients receiving antiretroviral treatment: a prospective randomised trial comparing an m-DOT strategy with standard-of-care in Kenya. SAHARA J 2010; 7:62–70.
43. Pomeroy ECRA, Laningham VL, Walker RJ. ‘Straight Talk’: The effectiveness of a psychoeducational group intervention for heterosexuals with HIV/AIDS. Res Social Work Pract 1997; 7:149–164.
44. Brown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: what have we learned?. AIDS Educ Prev 2003; 15:49–69.
45. Sengupta S, Banks B, Jonas D, Miles MS, Smith GC. HIV interventions to reduce HIV/AIDS stigma: a systematic review. AIDS Behav 2011; 15:1075–1087.
46. Rao D, Desmond M, Andrasik M, Rasberry T, Lambert N, Cohn SE, Simoni J. Feasibility, acceptability, and preliminary efficacy of the unity workshop: an internalized stigma reduction intervention for African American women living with HIV. AIDS Patient Care STDS 2012; 26:614–620.
47. Tshabalala JVM. Developing a cognitive behavioural therapy model to assist women to deal with HIV and stigma. South Afr J Psychol 2011; 41:17–28.
48. Pantelic M, Steinert JI, Park J, Mellors S, Murau F. ‘Management of a spoiled identity’: systematic review of interventions to address self-stigma among people living with and affected by HIV. BMJ Global Health 2019; 4:e001285.
49. Bos AE, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: the importance of theory- and evidence-based interventions. Psychol Health Med 2008; 13:450–460.
50. Modi RAK, Knudson A, Westfall AO, Keruly J, Crane HM, et al. Assessing effects of behavioral intervention on treatment outcomes among patients initiating HIV care: Rationale and design of iENGAGE intervention trial. Contemp Clin Trials 2018; 69:48–54.
51. Kay ES, Batey DS, Mugavero MJ. The HIV treatment cascade and care continuum: updates, goals, and recommendations for the future. AIDS Res Ther 2016; 13:35.
52. Dlamini PS, Wantland D, Makoae LN, Chirwa M, Kohi TW, Greeff M, et al. HIV stigma and missed medications in HIV-positive people in five African countries. AIDS Patient Care STDS 2009; 23:377–387.
53. Bangsberg DR, Hecht FM, Clague H, Charlebois ED, Ciccarone D, Chesney M, Moss A. Provider assessment of adherence to HIV antiretroviral therapy. J Acquir Immune Defic Syndr 2001; 26:435–442.
54. Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, et al. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr 2012; 59:86–93.
55. Workowski KA, Bolan GA. Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep 2015; 64 (RR-03):1–137.
56. Horberg MA, Hurley LB, Silverberg MJ, Klein DB, Quesenberry CP, Mugavero MJ. Missed office visits and risk of mortality among HIV-infected subjects in a large healthcare system in the United States. AIDS Patient Care STDS 2013; 27:442–449.
57. Tripathi A, Youmans E, Gibson JJ, Duffus WA. The impact of retention in early HIV medical care on viro-immunological parameters and survival: a statewide study. AIDS Res Hum Retroviruses 2011; 27:751–758.
58. Katz IT, Essien T, Marinda ET, Gray GE, Bangsberg DR, Martinson NA, De Bruyn G. Antiretroviral refusal among newly diagnosed HIV-infected adults in Soweto, South Africa. AIDS 2011; 25:2177–2181.
59. Mugavero MJ, Lin HY, Willig JH, Westfall AO, Ulett KB, Routman JS, et al. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis 2009; 48:248–256.
60. Eaton LA, Earnshaw VA, Maksut JL, Thorson KR, Watson RJ, Bauermeister JA. Experiences of stigma and healthcare engagement among Black MSM newly diagnosed with HIV/STI. J Behav Med 2018; 41:458–466.
61. Tsai AC, Bangsberg DR, Bwana M, Haberer JE, Frongillo EA, Muzoora C, et al. How does antiretroviral treatment attenuate the stigma of HIV? Evidence from a cohort study in rural Uganda. AIDS Behav 2013; 17:2725–2731.
62. Earnshaw VA, Reed NM, Watson RJ, Maksut JL, Allen AM, Eaton LA. Intersectional internalized stigma among black gay and bisexual men: a longitudinal analysis spanning HIV/sexually transmitted infection diagnosis. J Health Psychol 2019. 1–12.
63. Amico KR. A situated-information motivation behavioral skills model of care initiation and maintenance (sIMB-CIM): an IMB model based approach to understanding and intervening in engagement in care for chronic medical conditions. J Health Psychol 2011; 16:1071–1081.
64. Fisher JD, Fisher WA, Amico KR, Harman JJ. An information-motivation-behavioral skills model of adherence to antiretroviral therapy. Health Psychol 2006; 25:462–473.
65. Turan B, Rice WS, Crockett KB, Johnson M, Neilands TB, Ross SN, et al. Longitudinal association between internalized HIV stigma and antiretroviral therapy adherence for women living with HIV: the mediating role of depression. AIDS 2019; 33:571–576.
66. Turan B, Fazeli PL, Raper JL, Mugavero MJ, Johnson MO. Social support and moment-to-moment changes in treatment self-efficacy in men living with HIV: psychosocial moderators and clinical outcomes. Health Psychol 2016; 35:1126–1134.
67. Fabian KE, Huh D, Kemp CG, Nevin PE, Simoni JM, Andrasik M, et al. Moderating factors in an antistigma intervention for African American Women with HIV in the United States: a secondary analysis of the UNITY Trial. AIDS Behav 2019; 23:2432–2442.
68. Shaw S, Modi R, Mugavero M, Golin C, Quinlivan EB, Smith LR, et al. HIV standard of care for ART adherence and retention in care among HIV medical care providers across four CNICS clinics in the US. AIDS Behav 2019; 23:947–956.
69. Bunn JY, Solomon SE, Miller C, Forehand R. Measurement of stigma in people with HIV: a reexamination of the HIV Stigma Scale. AIDS Educ Prev 2007; 19:198–208.
70. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatric annals 2002; 32:509–515.
71. Carver CS. You want to measure coping but your protocol's too long: consider the brief COPE. Int J Behav Med 1997; 4:92–100.
72. Amico K, Modi R, Westfall A, Willig J, Keruly J, Napravnik S, et al. Viral suppression among people initiating HIV care: outcomes from iENGAGE Trial. In: Conference on Retroviruses and Opportunistic Infections. Seattle, Washington, 2019.
73. Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. Guilford Press: New York; 2013.
74. Christopoulos KA, Neilands TB, Hartogensis W, Geng EH, Sauceda J, Mugavero MJ, et al. Internalized HIV stigma is associated with concurrent viremia and poor retention in a cohort of US patients in HIV care. J Acquir Immune Defic Syndr 2019; 82:116–123.
75. Turan B, Stringer KL, Onono M, Bukusi EA, Weiser SD, Cohen CR, Turan JM. Linkage to HIV care, postpartum depression, and HIV-related stigma in newly diagnosed pregnant women living with HIV in Kenya: a longitudinal observational study. BMC Pregnancy Childbirth 2014; 14:400.
76. Pagoto S, McDermott MM, Reed G, Greenland P, Mazor KM, Ockene JK, et al. Can attention control conditions have detrimental effects in behavioral medicine randomized trials?. Psychosom Med 2013; 75:137–143.
Keywords:

coping; depression; HIV; intervention; new-to-care; stigma

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.