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Buffering Internalization of HIV Stigma

Implications for Treatment Adherence and Depression

Turan, Bulent PhD*; Crockett, Kaylee B. PhD*; Buyukcan-Tetik, Asuman PhD; Kempf, Mirjam-Colette PhD, MPH; Konkle-Parker, Deborah PhD, FNP, FAAN§; Wilson, Tracey E. PhD; Tien, Phyllis C. MD¶,#; Wingood, Gina ScD, MPH**; Neilands, Torsten B. PhD; Johnson, Mallory O. PhD; Weiser, Sheri D. MD, MPH††; Turan, Janet M. PhD‡‡

JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1, 2019 - Volume 80 - Issue 3 - p 284–291
doi: 10.1097/QAI.0000000000001915
Prevention Research

Background: One mechanism through which social stigma of HIV affects health outcomes for people living with HIV (PLWH) is through internalization of stigma. However, this transformation of social stigma in the community into internalized stigma may not be of the same magnitude for all PLWH. We examined the moderating effects of 3 personality traits—fear of negative social evaluation, attachment-related anxiety, and dispositional resilience—in transforming perceived stigma in the community into internalized stigma. Furthermore, we investigated downstream effects of these moderated associations on depressive symptoms and antiretroviral treatment (ART) adherence.

Setting/Methods: In study 1, data from 203 PLWH in the Southeast United States were analyzed controlling for age, sex, education, race, and time on ART. In study 2, data from 453 women in a multisite study were analyzed controlling for age, education, race, time on ART, and substance use.

Results: In both studies, fear of negative evaluation and attachment-related anxiety moderated the effect of perceived HIV stigma in the community on internalized HIV stigma: People higher on those moderating variables had stronger associations between perceived stigma in the community and internalized stigma. In study 2, resilience was assessed and also moderated the effect of perceived HIV stigma in the community on internalized stigma. In moderated mediation models, fear of negative evaluation, attachment-related anxiety, and resilience moderated the indirect effect of perceived HIV stigma in the community on ART adherence and depression through internalized stigma.

Conclusions: Interventions to assuage internalization of HIV stigma should focus on bolstering attachment-related security, social competence, and resilience.

*Department of Psychology, University of Alabama at Birmingham, Birmingham, AL;

Psychology Program, Sabanci University, Istanbul, Turkey;

Schools of Nursing, Public Health, and Medicine, University of Alabama at Birmingham, Birmingham, AL;

§Department of Medicine/Infectious Diseases, University of Mississippi Medical Center, Jackson, MS;

Department of Community Health Sciences, School of Public Health, State University of New York Downstate Medical Center, Brooklyn, NY;

Department of Medicine, University of California, San Francisco, San Francisco, CA;

#Medical Service, Department of Veteran Affairs Medical Center, San Francisco, CA;

**Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY;

††Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA; and

‡‡Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL.

Correspondence to: Bulent Turan, PhD, Department of Psychology, University of Alabama at Birmingham, 415 Campbell Hall, Birmingham, AL 35294-1170 (e-mail:

Supported by Women's Interagency HIV Study (WIHS) substudy grants from the National Institute of Mental Health, R01MH104114 and R01MH095683. The contents of this publication are solely the responsibility of the authors and do not represent the official views of the National Institutes of Health (NIH). WIHS (Principal Investigators): UAB-MS WIHS (M-C.K. and D. K.-P.), U01-AI-103401; Atlanta WIHS (Ighovwerha Ofotokun and G.W.), U01-AI-103408; Bronx WIHS (Kathryn Anastos and Anjali Sharma), U01-AI-035004; Brooklyn WIHS (Howard Minkoff and Deborah Gustafson), U01-AI-031834; Chicago WIHS (Mardge Cohen and Audrey French), U01-AI-034993; Metropolitan Washington WIHS (Seble Kassaye), U01-AI-034994; Miami WIHS (Margaret Fischl and Lisa Metsch), U01-AI-103397; UNC WIHS (Adaora Adimora), U01-AI-103390; Connie Wofsy Women's HIV Study, Northern California (Ruth Greenblatt, Bradley Aouizerat, and Phyllis Tien), U01-AI-034989; WIHS Data Management and Analysis Center (Stephen Gange and Elizabeth Golub), U01-AI-042590; Southern California WIHS (Joel Milam), U01-HD-032632 (WIHS I–WIHS IV). The WIHS is funded primarily by the National Institute of Allergy and Infectious Diseases (NIAID), with additional cofunding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Cancer Institute (NCI), the National Institute on Drug Abuse (NIDA), and the National Institute on Mental Health (NIMH). Targeted supplemental funding for specific projects is also provided by the National Institute of Dental and Craniofacial Research (NIDCR), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), the National Institute on Deafness and other Communication Disorders (NIDCD), and the NIH Office of Research on Women's Health. WIHS data collection is also supported by UL1- TR000004 (UCSF CTSA), UL1-TR000454 (Atlanta CTSA), and P30-AI-050410 (UNC CFAR). 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. Trainee support was provided by the Agency for Healthcare Research and Quality (AHRQ 2T32HS013852-16).

The authors have no conflicts of interest to disclose.

B.T. and K.B.C. contributed equally to this manuscript.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received July 22, 2018

Accepted October 26, 2018

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