title: Mechanisms for the Negative Effects of Internalized HIV-Related Stigma on Antiretroviral Therapy Adherence in Women: The Mediating Roles of Social Isolation and Depression.
abstract: Internalization of HIV-related stigma may inhibit a person's ability to manage HIV disease through adherence to treatment regimens. Studies, mainly with white men, have suggested an association between internalized stigma and suboptimal adherence to antiretroviral therapy (ART). However, there is a scarcity of research with women of different racial/ethnic backgrounds and on mediating mechanisms in the association between internalized stigma and ART adherence.
  
  
  
  The Women's Interagency HIV Study (WIHS) is a multicenter cohort study. Women living with HIV complete interviewer-administered questionnaires semiannually. Cross-sectional analyses for the current article included 1168 women on ART for whom data on medication adherence were available from their last study visit between April 2013 and March 2014, when the internalized stigma measure was initially introduced.
  
  
  
  The association between internalized stigma and self-reported suboptimal ART adherence was significant for those in racial/ethnic minority groups (AOR = 0.69, P = 0.009, 95% CI: 0.52 to 0.91), but not for non-Hispanic whites (AOR = 2.15, P = 0.19, 95% CI: 0.69 to 6.73). Depressive symptoms, loneliness, and low perceived social support mediated the association between internalized stigma and suboptimal adherence in the whole sample, as well as in the subsample of minority participants. In serial mediation models, internalized stigma predicted less-perceived social support (or higher loneliness), which in turn predicted more depressive symptoms, which in turn predicted suboptimal medication adherence.
  
  
  
  Findings suggest that interconnected psychosocial mechanisms affect ART adherence, and that improvements in adherence may require multifaceted interventions addressing both mental health and interpersonal factors, especially for minority women.
authors.affiliation: *Department of Psychology, University of Alabama at Birmingham, Birmingham, AL;†Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL;‡Department of Medicine, Stroger Hospital, Chicago, IL;§Department of Community Health Sciences, School of Public Health, State University of New York Downstate Medical Center, Brooklyn, NY;‖School of Medicine and UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC;¶Department of Family Medicine, Georgetown University Medical Center, Washington, DC;#Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY;**Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD;††School of Medicine, Emory University, Atlanta, GA;‡‡Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY;§§Department of Medicine, University of California San Francisco and Medical Service, Department of Veteran Affairs Medical Center, San Francisco, CA; and‖‖Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA.
authors.forename: Bulent
authors.initials: B
authors.lastname: Turan
authors.forename: Whitney
authors.initials: W
authors.lastname: Smith
authors.forename: Mardge H
authors.initials: MH
authors.lastname: Cohen
authors.forename: Tracey E
authors.initials: TE
authors.lastname: Wilson
authors.forename: Adaora A
authors.initials: AA
authors.lastname: Adimora
authors.forename: Daniel
authors.initials: D
authors.lastname: Merenstein
authors.forename: Adebola
authors.initials: A
authors.lastname: Adedimeji
authors.forename: Eryka L
authors.initials: EL
authors.lastname: Wentz
authors.forename: Antonina G
authors.initials: AG
authors.lastname: Foster
authors.forename: Lisa
authors.initials: L
authors.lastname: Metsch
authors.forename: Phyllis C
authors.initials: PC
authors.lastname: Tien
authors.forename: Sheri D
authors.initials: SD
authors.lastname: Weiser
authors.forename: Janet M
authors.initials: JM
authors.lastname: Turan
mesh_terms: D019380:Anti-HIV Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D003863:Depression / Q000150:complications* / Q000453:epidemiology; D004192:Discrimination, Psychological; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000453:epidemiology / Q000523:psychology*; D006801:Humans; D055118:Medication Adherence / Q000523:psychology*; D008875:Middle Aged; D012934:Social Isolation / Q000523:psychology*; D057545:Social Stigma; D012944:Social Support; D011795:Surveys and Questionnaires; D014481:United States / Q000453:epidemiology; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents