title: HIV stigma and unprotected sex among PLWH in KwaZulu-Natal, South Africa: a longitudinal exploration of mediating mechanisms.
abstract: Social and structural factors including HIV stigma are theorized to drive global disparities in HIV prevalence. This study tests whether HIV self-stigma, or experiences of stigma at the individual level, is associated with engagement in unprotected sex among people living with HIV (PLWH) in KwaZulu-Natal, South Africa, where 37.4% of adults are living with HIV compared with 0.8% worldwide. It further explores whether depressive symptoms, HIV status disclosure to sex partners, and/or condom use attitudes mediate potential associations between HIV self-stigma and unprotected sex. Participants, including 924 PLWH, were recruited from primary care clinics and completed baseline, 6-, 12-, and 18-month survey assessments between 2008 and 2011. Hierarchical linear modeling analyses were used to examine longitudinal within-subjects associations between HIV self-stigma, mediators, and unprotected sex with both HIV-negative/unknown and HIV-positive partners. Results demonstrate that HIV self-stigma was prospectively associated with greater likelihood of unprotected sex with HIV-negative/unknown partners. None of the variables explored significantly mediated this association. HIV self-stigma was also prospectively associated with greater likelihood of unprotected sex with HIV-positive partners via the mediators of greater depressive symptoms and more negative condom use attitudes. The current study suggests that HIV self-stigma undermines HIV secondary prevention and care efforts among PLWH in KwaZulu-Natal. It is therefore critical to address HIV stigma at the social/structural level to reduce HIV self-stigma at the individual level and ultimately curb global disparities in HIV prevalence. In the absence of widespread social/structural change, interventions that treat depressive symptoms and encourage more positive condom use attitudes despite the existence of HIV stigma may buffer associations between HIV self-stigma and unprotected sex with HIV-positive partners among PLWH in KwaZulu-Natal.
authors.affiliation: a Center for Interdisciplinary Research on AIDS , Yale University , New Haven , CT , USA.
authors.forename: Valerie A
authors.initials: VA
authors.lastname: Earnshaw
authors.forename: Laramie R
authors.initials: LR
authors.lastname: Smith
authors.forename: Paul A
authors.initials: PA
authors.lastname: Shuper
authors.forename: William A
authors.initials: WA
authors.lastname: Fisher
authors.forename: Deborah H
authors.initials: DH
authors.lastname: Cornman
authors.forename: Jeffrey D
authors.initials: JD
authors.lastname: Fisher
mesh_terms: D000328:Adult; D017280:Condoms / Q000706:statistics & numerical data*; D003863:Depression / Q000453:epidemiology* / Q000517:prevention & control; D005260:Female; D015658:HIV Infections / Q000453:epidemiology* / Q000517:prevention & control / Q000523:psychology; D007722:Health Knowledge, Attitudes, Practice; D006306:Health Surveys; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D011203:Poverty; D015995:Prevalence; D012107:Research Design; D012307:Risk Factors; D012747:Sexual Partners; D057545:Social Stigma; D012944:Social Support; D013019:South Africa / Q000453:epidemiology; D011795:Surveys and Questionnaires; D047568:Unsafe Sex / Q000706:statistics & numerical data*
keywords: HIV; South Africa; depressive symptoms; disclosure; stigma; unprotected sex