Despite the importance of HIV medication adherence for effective treatment of HIV,1 population-based estimates in the United States (US) indicate suboptimal levels of adherence to antiretroviral therapy (ART).2–4 An increasing body of literature from a variety of geographic and cultural settings suggests that HIV-related stigma is a psychosocial factor negatively associated with HIV medication adherence.5,6 Several dimensions of HIV-related stigma have been explored within this context, including enacted stigma (past experiences of discrimination) and perception of stigmatization in the community.7–9 Internalization of these stigmas, or acceptance of stigmatizing beliefs that are present in the community—and feelings of shame and lower self-worth as a consequence—may be the crucial factor in the stigma–adherence association.10–13 Psychosocial consequences of HIV-related internalized stigma (ie, self-imposed exclusion, avoidance, fears of rejection, social withdrawal, and depression) are hypothesized to play a major role in inhibiting a person's ability to adhere to HIV treatment.11,12,14,15
Longitudinal studies in resource-limited settings in Uganda have suggested that internalized stigma predicts decreased levels of perceived social support and separately increase in depressive symptom severity.16,17 Research also suggests that loneliness and lack of perceived social support are associated with depressive symptoms among persons living with HIV.18,19 Furthermore, meta-analyses and systematic reviews also support the notion that internalized HIV-related stigma,6 lack of social support,20 and depressive symptoms21 predict suboptimal ART adherence.
Despite the mounting evidence for the negative effects of internalized HIV stigma, few US studies have investigated whether loneliness, social support, depression, or related psychosocial factors operate as mediating mechanisms for the negative effects of internalized HIV stigma on medication adherence. It is important for the field of HIV research to understand why or how internalized stigma leads to nonoptimal adherence.22 At the present time, only a few studies explored mediating mechanisms in this relationship in the USA.15,23–25 Rao et al reported that the effect of internalized and enacted stigma on medication adherence is mediated by depression. Sayles et al reported an indirect effect between a multidimensional measure of internalized stigma and medication adherence that was mediated by mental health. Findings by DiIorio et al suggested that the relationship between stigma and adherence is mediated by self-efficacy and depression. Helms et al15 reported that interpersonal worries mediated the effect of internalized stigma on adherence.
However, studies examining depression used HIV stigma scales assessing internalized stigma in combination with other dimensions of stigma (eg, perceptions of stigma in the community, disclosure concerns, enacted stigma). Although internal and external stigma are intrinsically linked,14 internalized stigma is acceptance that the external stigma is justified and applies to the self, making people living with HIV feel that they have a tarnished character. The other dimensions of stigma, on the other hand, typically involve interpersonal experiences and perceptions of other people's attitudes. Internalized stigma appears to operate differently from other dimensions of HIV stigma on indicators of affective and behavioral health and well-being.12 Thus, internalization of stigma may differentially predict depressive symptoms and adherence behavior as compared to other dimensions of stigma. Research in this area may develop a theoretical understanding of these relationships by distinguishing between pure internalized stigma scales and other dimensions of stigma. Furthermore, the existing literature has not yet elucidated whether and how multiple psychosocial constructs may work together to affect the relationship between internalized stigma and adherence in a single model.
Additionally, given epidemiologic reports that depression is more prevalent among women than men26,27 and that depressive symptoms are related to neighborhood racial/ethnic composition and racial discrimination,28,29 it is important to identify whether these factors have similar consequences for adherence in samples not consisting of predominantly male25 and Caucasian samples of patients.23 Empirical evidence also suggests that there are race and gender disparities in the likelihood of receiving social support and in the effects of social support on health.30–32 Moreover, black and other racial/ethnic minority women are disproportionately affected by HIV infection in the USA,33 and the burden of HIV among minorities is exacerbated by disparities in levels of ART adherence by race/ethnicity and gender.3,34,35 Therefore, potential predictors of adherence may operate differently within a more diverse sample.
The purpose of the present study was to test whether social isolation (loneliness and lack of social support) and depressive symptoms mediate the relationship between internalized stigma and HIV medication nonadherence in a large sample of racially diverse women living with HIV across the USA. We also examined whether these associations differ by race. Given that several separate studies provided support for the theoretically plausible links between internalized stigma and higher social isolation; higher social isolation and depressive symptoms; and depressive symptoms and ART non-adherence; we hypothesized a serial mediation model: internalized stigma → higher social isolation (higher loneliness or lower social support) → depressive symptoms → ART nonadherence. This model posits a chain effect of internalized stigma on nonadherence sequentially through loneliness (and lower social support) and higher depressive symptoms: Internalized stigma may lead to social isolation (a potential interpersonal manifestation of feelings of lower self-value), which may lead to depressive symptoms that may subsequently be associated with nonoptimal adherence.
Participants and Procedures
Participants were women living with HIV enrolled in the Women's Interagency HIV Study (WIHS), a multicenter longitudinal cohort study.36,37 As part of this ongoing cohort study, women living with HIV complete detailed interviewer-administered questionnaires, physical examinations, and specimen collection semiannually. Analyses for the current article included 1168 women currently on ART for whom data on medication adherence were available from their last study visit between April 2013 and March 2014 (which excludes 149 women from the analyses), when a measure of internalized stigma was initially added to the battery of measures. Data were collected from 9 WIHS sites in various regions of the United States–San Francisco/Bay Area, CA; Bronx/Manhattan, NY; Brooklyn, NY; Washington, DC; Chicago, IL; Atlanta, GA; Chapel Hill, NC; Miami, FL; and Birmingham, AL/Jackson, MS. Participants provided written informed consent and were compensated for participation. This protocol was approved by the Institutional Review Board at each study site's institution and by the WIHS Executive Committee. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000.
HIV medication adherence was assessed by self-report of how often participants took their HIV medication as prescribed over the past 6 months (1 = 100% of the time; 2 = 95–99% of the time; 3 = 75–94% of the time; 4 = <75% of the time; 5 = I haven't taken any of my prescribed medications). Self-report measures of ART adherence have exhibited validity and reliability as a marker of clinical impact.38–40 A 95% ART adherence rate has been used as the cutoff for optimal versus suboptimal adherence in previous studies.41,42 Thus, we created a single variable, dichotomized at 95% or higher versus lower than 95%.
Internalized HIV-Related Stigma
Internalized HIV-related stigma was assessed with the negative self-image subscale of the revised HIV Stigma Scale43 adapted from Berger et al.44 This subscale includes 7 items rated on a 4-point scale (strongly disagree to strongly agree). A sample item is “I feel I'm not as good as others because I have HIV/AIDS”. This scale showed high internal consistency and test–retest reliability in previous studies.45,46 Cronbach's alpha reliability coefficient for the 7-item subscale was 0.91 in the current sample.
The 20-item Center for Epidemiological Studies Depression (CES-D) scale47 is used to assess depressive symptoms in the WIHS. Response options range from 0 to 3 (0 = Rarely or None of the Time, 3 = Most or Almost All the Time). Depressive symptoms, as measured by the CES-D, have been shown to predict adherence in previous studies.48,49 The sum of the 20 items was used to assess depressive symptoms. The CES-D shows strong reliability in other literature,48,49 and in the present sample, Cronbach's alpha was 0.91.
Social Isolation (Social Support and Loneliness)
A shortened 15-item version of the MOS Social Support Survey50 was used to assess social support. The rating scale ranged from 1 (None of the time) to 5 (All of the time), where higher scores indicate more social support. The Cronbach's alpha was 0.97 in the current study. A shortened 3-item version of the R-UCLA Loneliness Scale51 was used to assess loneliness. The rating scale ranged from 1 (Hardly ever) to 3 (Often), where higher scores indicate more social isolation. The R-UCLA Loneliness Scale has evidence of moderate-to-high reliability from other studies.52,53 Cronbach's alpha in the current sample was 0.85.
We used descriptive statistics to examine the characteristics of the sample. To examine predictors of adherence, logistic regression analysis was conducted. The predictors were internalized stigma and covariates that previous research identified as important when examining stigma–adherence associations: race, age, time on ART, injected and noninjected drug use, income, and education. Adjusted odds ratios (AOR) controlling for these covariates were reported. A mediation model was used to test whether the association between internalized stigma and HIV medication adherence could be explained by depressive symptoms, social support, and loneliness using the mediation analysis with the bootstrap method for dichotomous outcomes developed by Hayes.54 Serial mediation analyses examined the effects of internalized stigma on adherence through the pathways of a series of mediators.54 These mediation analyses test the indirect effects of a predictor variable on outcomes through the mediator(s). We also conducted sensitivity analyses using medication adherence as a continuous dependent variable in multiple regression models. In these analyses, bootstrapping was used to accommodate the non-normal distribution of the adherence variable. All analyses were performed using SPSS (version 20).
Demographic and patient characteristics of the 1168 study participants are presented in Table 1. Over 88% of the participants were from racial/ethnic minority groups (blacks, Hispanics, and others), whereas non-Hispanic whites comprised only 12% of the sample. Given this distribution and the focus of the present study on marginalized minority groups in the USA, we used a dichotomized race variable in our analyses to compare non-Hispanic whites with all other racial/ethnic groups (Results were very similar when the 4-category race variable was used instead of the dichotomous race variable to examine the effect of stigma on adherence). The logistic regression models revealed that internalized HIV stigma was a significant predictor of nonoptimal adherence (AOR = 0.76, P = 0.042, 95% CI: 0.58 to 0.99). In this analysis, income, education, and injection drug use were not significant predictors (all P values >0.24), whereas being non-Hispanic white, of older age, having less time on ART, and not using noninjection drugs predicted better adherence (all P values <0.02). When we added the interaction between internalized stigma and race, the interaction term was also a significant predictor of adherence (AOR = 3.38, P = 0.026, 95% CI: 1.16 to 9.88). Therefore, logistic regression analyses were repeated for each race category separately. For the smaller sample of non-Hispanic whites, the effect was: AOR = 2.15, P = 0.188, 95% CI: 0.69 to 6.73. For women in racial/ethnic minority groups, the effect of internalized stigma on worse adherence was: AOR = 0.69, P = 0.009, 95% CI: 0.52 to 0.91. Based on this regression equation, we calculated the predicted probability for optimal adherence for a person who has an average level (ie, equal to the sample mean) of internalized stigma (and average levels on all covariates), which yielded a predicted probability of 0.61. In comparison, the predicted probability of optimal adherence for a person whose internalized stigma is one point lower than the sample mean was 0.66.
Therefore, we examined the mediation hypotheses for the racial/ethnic minority group only (Results were very similar (with significant indirect effects for all mediation analyses) when analyses were conducted for the whole sample instead). In this subsample, logistic regression analysis revealed that internalized stigma was no longer a significant predictor of adherence when depression was added to the model (AOR = 0.89, P = 0.464, 95% CI: 0.66 to 1.21). Depression was a significant predictor of worse adherence in this model (AOR = 0.96, P < 0.001, 95% CI: 0.95 to 0.98). The mediation analysis yielded a significant indirect effect of internalized stigma on worse adherence through depression (B = −0.24, SE = 0.06, 95% CI: −0.37 to −0.14). Thus, the effect of internalized stigma on adherence was mediated by depression as demonstrated in Figure 1.
Some of the items in the depression scale concern low self-worth [eg, “I felt I was just as good as other people (reversed)”] and may inflate associations with internalized stigma. Therefore, we also tested the mediation effect among minority women using the sum of only those items in the depression scale that are unrelated to low self-worth, which again revealed a significant indirect effect of internalized stigma on adherence through the pathway of depression (B = −0.21, SE = 0.05, 95% CI: −0.32 to −0.11). Social support was also a significant mediator of the effect of internalized stigma on lower adherence with a significant indirect effect (B = −0.098, SE = 0.042, 95% CI: −0.195 to −0.030). Finally, loneliness was also a significant mediator of the effect of internalized stigma on lower adherence with a significant indirect effect (B = −0.12, SE = 0.05, 95% CI: −0.23 to 0.02).
As seen in Figure 2, for minority women serial mediation analysis also yielded a significant indirect effect of stigma on lower ART adherence through less social support and through higher depression (B = −0.03, SE = 0.01, 95% CI: −0.06 to −0.01) (The serial mediation also yielded a significant serial indirect effect when the mean of the items in the depression scale that are unrelated to low self-worth were used). Figure 2 depicts the relationships between these variables, illustrating our findings that internalized stigma predicted less social support, which in turn predicted more depressive symptoms, which in turn predicted poorer medication adherence. Results were very similar when loneliness was used instead of social support in the analyses. The serial mediation also yielded a significant indirect effect of stigma on lower ART adherence through higher loneliness and through higher depression (B = −0.07, SE = 0.02, 95% CI: −0.12 to −0.02). Sensitivity analyses using adherence as a continuous dependent variable (using bootstrapping) are presented in Supplemental Digital Content 1, https://links.lww.com/QAI/A788. All of these analyses yielded results very similar to our original analyses using dichotomized adherence as the dependent variable.
The current study contributes to the extant literature by examining the mediating effect of social support or loneliness and subsequently, of depression, in the association between internalized HIV stigma and HIV medication adherence in women. The results indicate that HIV-related internalized stigma has an indirect and negative effect on adherence for women living with HIV mediated by social support or loneliness and depression. Initial analyses suggested that depressive symptoms, low social support, and loneliness each individually mediated the relationship between internalized stigma and poorer adherence. In further analyses, we found that less social support and separately higher loneliness operate through higher depression to mediate the relationship between internalized HIV stigma and lower adherence. These results were obtained for the whole sample, but the effect of internalized stigma on ART adherence was stronger for women in racial/ethnic minority groups than for non-Hispanic white women. This finding may contribute to our understanding of why non-white women living with HIV have lower adherence rates and worse outcomes than white women.55,56
The findings of the present study have important theoretical and practical implications. Our finding that depressive symptoms explain the relationship between HIV-related internalized stigma and medication adherence for women living with HIV support similar previous results from smaller samples consisting of mostly white men.23,25 Additional mechanisms through which stigma affects use of ART had yet to be elucidated, however. The current study indicated that less social support and higher loneliness may intensify depressive symptoms, which in turn predict poorer medication adherence. In general, this is in concordance with previous research suggesting that access to social support promotes ART adherence among people living with HIV by enabling them to overcome barriers to effective treatment.6,9
At this point in stigma research, it is very important to understand in a more nuanced manner the ways in which stigma affects the lives of people living with HIV.22 The experience of internalizing stigma leads to self-imposed isolation and exclusion from social situations,17,57 which may lead to reduced self-efficacy and depressive symptoms such as disempowerment, helplessness, inability to concentrate, and feelings of negativity and anguish.14,47 It is likely that these symptoms make it more difficult to adhere to ART. The presence of depressive symptoms may even affect one's desire for self-preservation and thus contribute to the tendency to neglect self-care needs.48 It is possible that these relationships also operate in a bidirectional manner. Existing literature suggests that effective ART adherence is associated with decreased depressive symptom severity.21 Depression could lead to lower social support, given that research suggests that nondepressed individuals show patterns of negative affect and a tendency to socially reject depressed individuals after a social interaction with them.58 Furthermore, lower social support could lead to more internalized stigma, given that persons living with HIV often draw on social support to minimize the harmful influences of stigma.6
An understanding of these interconnected factors affecting HIV medication adherence provides insight into what conditions/situations can potentially be targeted through interventions. Our findings contribute to the existing literature by implicating multiple stages at which we may be able to intervene to improve HIV-related health outcomes (ie, 1—internalization of stigma; 2—lack of social support or loneliness; and 3—depression). Programs aiming to improve ART adherence for women living with HIV may benefit from targeted strategies to address all 3 of these factors. Some depression treatment interventions have yielded promising results in improving adherence,59,60 but others resulted in no effect.61,62 Future intervention studies should examine the effectiveness of programs that seek to address depression, internalized stigma, and lack of social support simultaneously.
The strengths of the current study include the use of detailed and reliable measurement tools—including a multi-item measure of internalized stigma specific to HIV that has shown good evidence of construct and discriminant validity43—and measures of social support and loneliness not previously used to explore these relationships. Compared to previous studies,23,49 our study included a larger sample of racial/ethnic minority participants, who may be more representative of the population with least engagement in HIV care,55 the highest risk of HIV mortality in the USA,56 and according to the present results, may be more strongly affected by stigma. Furthermore, our sample was comprised of women living with HIV who represent multiple geographically diverse sites within the USA, rather than a single site, which may also enable greater generalizability. Finally, we used mediation modeling using bootstrapping to examine the interconnected relationships, which allowed us to explore the interpersonal and intrapersonal mechanisms in the association between internalized stigma and HIV medication adherence.
Limitations of the study include the use of cross-sectional data, which prevents us from inferring causal relationships. However, our study findings are consistent with previous research and theory, which suggests that constructs similar to internalized stigma, such as self-esteem, lead to depression longitudinally, but that prior depression does not predict later self-esteem.63 Our findings also lend theoretical support to causal models of the relationships between internalized stigma and social support,17 and depression separately,16 found in longitudinal designs in Uganda. Future studies using longitudinal designs or interventions are required to further elucidate causal relationships between social support and depressive symptoms, as well as depressive symptoms and adherence, and to confirm our hypothesized directionality.
An additional limitation is that there may be unobserved variables that are associated with both the mediators and the outcome, which may lead to biased results. We controlled for some of the variables that are known to predict ART adherence. However, there may be other variables not measured in our study that are associated with both social support (or loneliness) and adherence. It is also possible that unobserved potential mediator variables exist that are associated with our observed mediators and confound the mediation. These difficulties in interpretation are inherent in every mediation analysis because it is not possible to experimentally manipulate both the predictor and the mediator in a single study. Future research examining other theoretically relevant variables and using longitudinal designs may contribute to a better understanding of mediating mechanisms by providing analyses from different perspectives.
We examined predictors of adherence using a self-reported measure of adherence, which may be subject to response bias. Nevertheless, an extensive literature review indicated that brief self-reported measures of ART adherence such as that used in the current study are robust and reliable.38 Future studies examining associations with ART adherence may consider use of objective markers of adherence, such as antiretroviral concentrations in hair samples.
Our findings suggest that internalized stigma and poor adherence are indirectly related. This relationship is mediated by lack of social support, loneliness, and depressive symptoms. Further research can use these findings to develop multifaceted interventions to help women living with HIV to obtain mental health treatment and/or build skills to deal with these social and psychological factors, and evaluate the impact of such interventions on adherence.
We wish to acknowledge the assistance of the WIHS program staff and the contributions of the participants who enrolled in this study.
1. Gunthard HF, Aberg JA, Eron JJ, et al.. Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA. 2014;312:410–425.
2. Beer L, Heffelfinger J, Frazier E, et al.. Use of and adherence to antiretroviral therapy in a large U.S. Sample of HIV-infected adults in care, 2007-2008. Open AIDS J. 2012;6:213–223.
3. Beer L, Skarbinski J. Adherence to antiretroviral therapy among HIV-infected adults in the United States. AIDS Educ Prev. 2014;26:521–537.
4. Centers for Disease Control and Prevention. Vital signs: HIV prevention through care and treatment–United States. MMWR Morb Mortal Wkly Rep. 2011;60:1618–1623.
5. Langebeek N, Gisolf EH, Reiss P, et al.. Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis. BMC Med. 2014;12:142.
6. Katz IT, Ryu AE, Onuegbu AG, et al.. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc. 2013;16(3 suppl 2):18640.
7. Wolitski RJ, Pals SL, Kidder DP, et al.. The effects of HIV stigma on health, disclosure of HIV status, and risk behavior of homeless and unstably housed persons living with HIV. AIDS Behav. 2009;13:1222–1232.
8. Dlamini PS, Wantland D, Makoae LN, et al.. HIV stigma and missed medications in HIV-positive people in five African countries. AIDS Patient Care STDS. 2009;23:377–387.
9. Li MJ, Murray JK, Suwanteerangkul J, et al.. Stigma, social support, and treatment adherence among HIV-positive patients in Chiang Mai, Thailand. AIDS Educ Prev. 2014;26:471–483.
10. Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6:309–319.
11. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS Behav. 2009;13:1160–1177.
12. Earnshaw VA, Smith LR, Chaudoir SR, et al. PLWH: a test of the HIV stigma framework. AIDS Behav. 2013.
13. Earnshaw VA, Smith LR, Chaudoir SR, et al.. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013;17:1785–1795.
14. Brouard PA. Closer look: the internalization of stigma related to HIV. In: (USAID) USAfID, 2006.
15. Helms CB, Turan JM, Atkins G, et al.. Interpersonal mechanisms contributing to the association between hiv-related internalized stigma and medication adherence. AIDS Behav. 2016 Feb 10; Epub ahead of print.
16. Tsai AC, Bangsberg DR, Frongillo EA, et al.. 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.
17. Takada S, Weiser SD, Kumbakumba E, et al.. The dynamic relationship between social support and HIV-related stigma in rural Uganda. Ann Behav Med. 2014;48:26–37.
18. Vyavaharkar M, Moneyham L, Corwin S, et al.. 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.
19. Rotheram-Borus MJ, Stein JA, Jiraphongsa C, et al.. Benefits of family and social relationships for Thai parents living with HIV. Prev Sci. 2010;11:298–307.
20. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23:207–218.
21. Gonzalez JS, Batchelder AW, Psaros C, et al.. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011;58:181–187.
22. Kalichman SC. The Harms of Internalized AIDS Stigma: a Comment on Tsai et al. Ann Behav Med. 2013;46:256–257.
23. Rao D, Feldman BJ, Fredericksen RJ, et al.. A structural equation model of HIV-related stigma, depressive symptoms, and medication adherence. AIDS Behav. 2012;16:711–716.
24. Sayles JN, Wong MD, Kinsler JJ, et al.. 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.
25. DiIorio C, McCarty F, Depadilla L, et al.. Adherence to antiretroviral medication regimens: a test of a psychosocial model. AIDS Behav. 2009;13:10–22.
26. Nolen-Hoeksema S, Larson J, Grayson C. Explaining the gender difference in depressive symptoms. J Pers Soc Psychol. 1999;77:1061–1072.
27. Van de Velde S, Bracke P, Levecque K. Gender differences in depression in 23 European countries. Cross-national variation in the gender gap in depression. Soc Sci Med. 2010;71:305–313.
28. Mair C, Diez Roux AV, Osypuk TL, et al.. Is neighborhood racial/ethnic composition associated with depressive symptoms? the multi-ethnic study of atherosclerosis. Soc Sci Med. 2010;71:541–550.
29. Hudson DL, Puterman E, Bibbins-Domingo K, et al.. Race, life course socioeconomic position, racial discrimination, depressive symptoms and self-rated health. Soc Sci Med. 2013;97:7–14.
30. Glynn LM, Christenfeld N, Gerin W. Gender, social support, and cardiovascular responses to stress. Psychosom Med. 1999;61:234–242.
31. Fuhrer R, Stansfeld SA. How gender affects patterns of social relations and their impact on health: a comparison of one or multiple sources of support from “close persons”. Soc Sci Med. 2002;54:811–825.
32. Bell CN, Thorpe RJ, LaVeist TA. Race/ethnicity and Hypertension: the role of social support. Am J Hypertens. 2010;23:534–540.
33. Centers for Disease Control and Prevention. HIV Prevention in the United States: at a critical crossroads. In: National Center for HIV/AIDS VH, STD, and TB Prevention, ed. Atlanta, GA: U.S. Department of Health and Human Services; 2009.
34. Brown JL, Littlewood RA, Vanable PA. Social-cognitive correlates of antiretroviral therapy adherence among HIV-infected individuals receiving infectious disease care in a medium-sized northeastern US city. AIDS Care. 2013;25:1149–1158.
35. Kong MC, Nahata MC, Lacombe VA, et al.. Association between race, depression, and antiretroviral therapy adherence in a low-income population with HIV infection. J Gen Intern Med. 2012;27:1159–1164.
36. Barkan SE, Melnick SL, Preston-Martin S, et al.. The Women's Interagency HIV study. WIHS Collaborative study group. Epidemiology. 1998;9:117–125.
37. Bacon MC, von Wyl V, Alden C, et al.. The Women's Interagency HIV study: an Observational cohort Brings clinical Sciences to the Bench. Clin Diagn Lab Immunol. 2005;12:1013–1019.
38. Simoni JM, Kurth AE, Pearson CR, et al.. Self-report measures of antiretroviral therapy adherence: a review with recommendations for HIV research and clinical management. AIDS Behav. 2006;10:227–245.
39. Feldman BJ, Fredericksen RJ, Crane PK, et al.. Evaluation of the single-item self-rating adherence scale for use in routine clinical care of people living with HIV. AIDS Behav. 2013;17:307–318.
40. Wilson TE, Barrón Y, Cohen M, et al.. Adherence to antiretroviral therapy and its association with sexual behavior in a national sample of women with human immunodeficiency virus. Clin Infect Dis. 2002;34:529–534.
41. Kelso GA, Cohen MH, Weber KM, et al.. Critical consciousness, racial and gender discrimination, and HIV disease markers in African American women with HIV. AIDS Behav. 2014;18:1237–1246.
42. Dale S, Cohen M, Weber K, et al.. Abuse and resilience in relation to HAART medication adherence and HIV viral load among women with HIV in the United States. AIDS Patient Care STDS. 2014;28:136–143.
43. Bunn JY, Solomon SE, Miller C, et al.. Measurement of stigma in people with HIV: a Reexamination of the HIV stigma scale. AIDS Education Prev. 2007;19:198–208.
44. Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24:518–529.
45. Kipp AM, Audet CM, Earnshaw VA, et al.. Re-validation of the Van Rie HIV/AIDS-related stigma scale for use with people living with HIV in the United States. PLoS One. 2015;10:e0118836.
46. Varni SE, Miller CT, Solomon SE. Sexual behavior as a function of stigma and coping with stigma among people with HIV/AIDS in rural New England. AIDS Behav. 2012;16:2330–2339.
47. Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.
48. Tyer-Viola LA, Corless IB, Webel A, et al.. Predictors of medication adherence among HIV-positive women in North America. J Obstet Gynecol Neonatal Nurs. 2014;43:168–178.
49. Mitzel LD, Vanable PA, Brown JL, et al.. Depressive symptoms mediate the effect of hiv-related stigmatization on medication adherence among hiv-infected men who have sex with men. AIDS Behav. 2015;19:1454–1459.
50. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med. 1991;32:705–714.
51. Hughes ME, Waite LJ, Hawkley LC, et al.. A Short scale for measuring loneliness
in large Surveys: results from two population-based studies. Res Aging. 2004;26:655–672.
52. Hawkley LC, Thisted RA, Cacioppo JT. Loneliness
predicts reduced physical activity: cross-sectional & longitudinal analyses. Health Psychol. 2009;28:354–363.
53. Fortmann AL, Gallo LC, Roesch SC, et al.. Socioeconomic status, nocturnal blood pressure dipping, and psychosocial factors: a cross-sectional investigation in Mexican-American women. Ann Behav Med. 2012;44:389–398.
54. Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-based Approach. New York, NY: Guilford Press; 2013.
55. Hall H, Frazier EL, Rhodes P, et al.. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med. 2013;173:1337–1344.
56. Simard EP, Fransua M, Naishadham D, et al.. THe influence of sex, race/ethnicity, and educational attainment on human immunodeficiency virus death rates among adults, 1993-2007. Arch Intern Med. 2012;172:1591–1598.
57. Tsai AC, Bangsberg DR, Kegeles SM, et al.. Internalized stigma, social distance, and disclosure of HIV seropositivity in rural Uganda. Ann Behav Med. 2013;46:285–294.
58. Coyne JC. Depression and the response of others. J Abnorm Psychol. 1976;85:186–193.
59. Safren SA, O'Cleirigh C, Tan JY, et al.. A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals. Health Psychol. 2009;28:1–10.
60. Tsai AC, Weiser SD, Petersen ML, et al.. A marginal structural model to estimate the causal effect of antidepressant medication treatment on viral suppression among homeless and marginally housed persons with hiv. Arch Gen Psychiatry. 2010;67:1282–1290.
61. Tsai AC, Karasic DH, Hammer GP, et al.. Directly observed antidepressant medication treatment and HIV outcomes among homeless and marginally housed hiv-positive adults: a randomized controlled trial. Am J Public Health. 2013;103:308–315.
62. Pence BW, Gaynes BN, Adams JL, et al.. The effect of antidepressant treatment on HIV and depression outcomes: results from a randomized trial. AIDS. 2015;29:1975–1986.
63. Rieger S, Gollner R, Trautwein U, et al.. Low self-esteem Prospectively predicts depression in the Transition to Young Adulthood: a Replication of Orth, Robins, and Roberts (2008). J Pers Soc Psychol. 2016;110:e16–22.