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.
Center for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort study
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 seven CNICS sites and obtained cohort data through November 2017. We compared mean stigma levels by socio-demographic characteristics and used multivariable logistic regression, controlling for the same socio-demographic covariates, to evaluate the association between mean stigma and: 1) concurrent viremia; 2) missed visits; 3) poor visit constancy. We used inverse probability weighting (IPW) to account for differences between patients who did and did not undergo stigma assessment.
Of 13,183 CNICS patients, 6,448 (49%) underwent stigma assessment. Mean stigma was 1.99 (SD 1.07) and 28.6% agreed/strongly agreed with at least one stigma question. Patients <50 years, racial/ethnic minorities, cis-women, and heterosexuals had higher mean stigma. Mean stigma score was associated with concurrent viremia (AOR 1.13, 95% 1.02-1.25, p 0.02), missed visits (AOR 1.10, 95% CI 1.02-1.19, p 0.01), and poor visit constancy, though the effect on visit constancy was attenuated in the IPW model (AOR 1.05, 95% CI 0.98-1.13, p 0.17).
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.
1Division of HIV, ID, and Global Medicine, Department of Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
2Center for AIDS Prevention Studies, University of California San Francisco, San Francisco, California, USA
3Osher Center for Integrative Medicine, University of California San Francisco, San Francisco, California, USA
4Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
5Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle.
6Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
7Department of Medicine, University of California, San Diego
8Department of Medicine, Fenway Health, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
9Division of Infectious Diseases, University of North Carolina at Chapel Hill
Corresponding Author/Requests for Reprints: Katerina Christopoulos, MD, MPH Associate Professor of Medicine in Residence Division of HIV, ID, and Global Medicine University of California San Francisco 995 Potrero Ave, 4th Floor San Francisco, CA 94110 Tel 415-476-4082x440 Fax 415-476-6953 firstname.lastname@example.org
Conflicts of Interest and Sources of Funding: None related to this manuscript. Dr. Christopoulos has received investigator-initiated grant support from Gilead Sciences and has served as a community advisory board member for Gilead. This work was supported by National Institutes of Health R01 MH102198-S1 and R24 AI067039.
Previous Presentation: Presented in part at the 25th Conference on Opportunistic Infections and Retroviruses; March 4-7, 2018; Boston, Massachusetts.