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Internalized HIV Stigma Is Associated With Concurrent Viremia and Poor Retention in a Cohort of US Patients in HIV Care

Christopoulos, Katerina A. MD, MPHa; Neilands, Torsten B. PhDb; Hartogensis, Wendy PhD, MPHc; Geng, Elvin H. MD, MPHa; Sauceda, John PhD, MScb; Mugavero, Michael J. MD, MHScd; Crane, Heidi M. MD, MPHe; Fredericksen, Rob J. PhD, MPHe; Moore, Richard D. MDf; Mathews, William Christopher MDg; Mayer, Kenneth H. MDh; Chander, Geetanjali MD, MPHf; Hurt, Christopher B. MDi; Johnson, Mallory O. PhDb

JAIDS Journal of Acquired Immune Deficiency Syndromes: October 1, 2019 - Volume 82 - Issue 2 - p 116–123
doi: 10.1097/QAI.0000000000002117

Background: The relationship of internalized HIV stigma to key care cascade metrics in the United States is not well established using large-scale, geographically diverse data.

Setting: Center for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort study.

Methods: Beginning in February 2016, we administered a yearly, validated 4-item internalized HIV stigma scale (response scale 1 = strongly disagree to 5 = strongly agree, Cronbach's alpha 0.91) at 7 CNICS sites and obtained cohort data through November 2017. We compared mean stigma levels by sociodemographic characteristics and used multivariable logistic regression, controlling for the same sociodemographic covariates, to evaluate the association between mean stigma and (1) concurrent viremia; (2) missed visits; and (3) poor visit constancy. We used inverse probability weighting (IPW) to account for differences between patients who did and did not undergo stigma assessment.

Results: Of 13,183 CNICS patients, 6448 (49%) underwent stigma assessment. Mean stigma was 1.99 (SD 1.07), and 28.6% agreed/strongly agreed with at least 1 stigma question. Patients younger than 50 years, racial/ethnic minorities, cis-women, and heterosexuals had higher mean stigma. Mean stigma score was associated with concurrent viremia [adjusted odds ratio (AOR) 1.13, 95% confidence interval (CI): 1.02 to 1.25, P 0.02], missed visits (AOR 1.10, 95% CI: 1.02 to 1.19, P 0.01), and poor visit constancy, although the effect on visit constancy was attenuated in the IPW model (AOR 1.05, 95% CI: 0.98 to 1.13, P 0.17).

Conclusions: Higher internalized HIV stigma had a modest but statistically significant association with concurrent viremia and poor retention in care. Further inquiry with prospective analyses is warranted.

aDivision of HIV, ID, and Global Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA;

bDepartment of Medicine, Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, CA;

cOsher Center for Integrative Medicine, University of California San Francisco, San Francisco, CA;

dDivision of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL;

eDivision of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, WA;

fDepartment of Medicine, Johns Hopkins School of Medicine, Baltimore, MD;

gDepartment of Medicine, University of California, San Diego, CA;

hDepartment of Medicine, Fenway Health, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; and

iDivision of Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Correspondence to: Katerina A. Christopoulos, MD, MPH, Division of HIV, ID, and Global Medicine, University of California San Francisco, 995 Potrero Avenue, 4th Floor, San Francisco, CA 94110 (e-mail:

Supported by National Institutes of Health R01 MH102198-S1 and R24 AI067039. K.A.C. has received investigator-initiated grant support from Gilead Sciences and has served as a community advisory board member for Gilead.

Presented in part at the 25th Conference on Opportunistic Infections and Retroviruses; March 4–7, 2018; Boston, MA.

The authors have no conflicts of interest to disclose.

Received March 14, 2019

Accepted May 03, 2019

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