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Discrimination, Medical Distrust, Stigma, Depressive Symptoms, Antiretroviral Medication Adherence, Engagement in Care, and Quality of Life Among Women Living With HIV in North Carolina

A Mediated Structural Equation Model

Relf, Michael V. PhD, RN, FAANa,b; Pan, Wei PhDa; Edmonds, Andrew PhD, MSPHc; Ramirez, Catalina MPH, CCRPd; Amarasekara, Sathya MSa; Adimora, Adaora A. MD, MPHc,e

JAIDS Journal of Acquired Immune Deficiency Syndromes: July 1, 2019 - Volume 81 - Issue 3 - p 328–335
doi: 10.1097/QAI.0000000000002033
Clinical Science

Background: Women represent 23% of all Americans living with HIV. By 2020, more than 70% of Americans living with HIV are expected to be 50 years and older.

Setting: This study was conducted in the Southern United States—a geographic region with the highest number of new HIV infections and deaths.

Objective: To explore the moderating effect of age on everyday discrimination (EVD); group-based medical (GBM) distrust; enacted, anticipated, internalized HIV stigma; depressive symptoms; HIV disclosure; engagement in care; antiretroviral medication adherence; and quality of life (QOL) among women living with HIV.

Methods: We used multigroup structural equation modeling to analyze baseline data from 123 participants enrolled at the University of North Carolina at Chapel Hill site of the Women's Interagency HIV Study during October 2013–May 2015.

Results: Although age did not moderate the pathways hypothesized, age had a direct effect on internalized stigma and QOL. EVD had a direct effect on anticipated stigma and depressive symptoms. GBM distrust had a direct effect on depressive symptoms and a mediated effect through internalized stigma. Internalized stigma was the only form of stigma directly related to disclosure. Depressive symptoms were a significant mediator between GBM, EVD, and internalized stigma reducing antiretroviral therapy medication adherence, engagement in care, and QOL.

Conclusions: EVD, GBM, and internalized stigma adversely affect depressive symptoms, antiretroviral therapy medication adherence, and engagement in care, which collectively influence the QOL of women living with HIV.

aSchool of Nursing, Duke University, Durham, NC;

bDuke Global Health Institute, Duke University, Durham, NC;

cDepartment of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC;

dWomen's Interagency HIV Study, The University of North Carolina at Chapel Hill, Chapel Hill, NC; and

eSchool of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC.

Correspondence to: Michael V. Relf, PhD, RN, FAAN, Duke University School of Nursing, DUMC 3322, 307 Trent Drive, Durham, NC 57710 (e-mail:

Supported in part by the National Institute of Nursing Research (NINR, P30 NR014139-04S1 PD: M.V.R.; NINR, P30 NR014139S/Sharron Docherty and Donald. E. Bailey, PIs). Data in this manuscript were collected by the Women's Interagency HIV Study (WIHS), U01-AI-10339 (A.A.A.). 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). The WIHS is funded primarily by the National Institute of Allergy and Infectious Diseases (NIAID), with additional co-funding 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 P30-AI-050410 (UNC CFAR).

The authors have no conflicts of interest to disclose.

Received March 01, 2018

Accepted February 18, 2019

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