E L I S A D I A Z , P S Y . D .A S S I S T A N T P R O F E S S O R

D E P A R T M E N T O F P S Y C H I A T R Y A N D B E H A V I O R A L S C I E N C E SU N I V E R S I T Y O F M I A M I M I L L E R S C H O O L O F M E D I C I N E

HIV Stigma and Minority Women

HIV related Stigma

HIV has become one of the most stigmatizedhealth conditions in modern societies

Why? What makes HIV so different than other medical conditions?

HIV is associated with risky sexual behaviors, substance abuse and fears related to its possible contagiousness (1)

In 35% of countries with available data, over 50% of men and women report having discriminatory attitudes towards people living with HIV (1)

What is HIV related Stigma?

Co-occurrence of a label, a stereotype, separation, status loss, or discrimination in a context where power is exercised (2)

The collection of adverse attitudes, beliefs and actions of others against people living with or affected by HIV, which may result in deleterious internalized beliefs or actions taken by persons living with HIV infection that may result in negative health outcomes (2)

What is HIV related Stigma?

Stigma is experienced by individual PLWH as a series of stigma manifestations, including enacted and anticipated stigma (3)

Enacted stigma, or perceived experiences of discrimination from others in the past or present

Anticipated stigma, or expectations of discrimination from others in the future

What is HIV related Stigma?

Who is Impacted?

African American WomenHispanic WomenHaitian Women

Why?

HIV-infected women may experience multiple levels of stigma due to the labels and stereotypes commonly associated with being female, HIV-infected and socially marginalized (i.e., poor, low education, substance user, or racial/ethnic minority) (4,5)

Who is impacted?

Stigma has become a gendered phenomenon that affects increasing numbers of HIV-infected women worldwide.

In the United States (US), HIV-infected women often experience higher rates of personal (internalized) stigma than HIV-infected men Among women, recent shifts in the incidence of HIV infections have increased towards ethnic minority women paralleling the increasing susceptibility of this cohort to experience a stigmatizing event

Black women reported the highest rates of HIV-related stigma, higher than other minorities such as Asian and Latin individuals

(6,7)

Who is impacted?

African American women are particularly vulnerable to experiencing a stigmatizing event due to their over-representation among women infected with HIV, and due in part to the double standard that “blames” a woman’s behavior for becoming infected with HIV while excusing the behaviors of HIV-infected men

Haitian women (higher attention in FL, particularly Miami-Dade due to large presence, primarily due to geographic reasons)

(6,7)

Impact of HIV related stigma: Why it matters

Psychological problems Feelings of shame, depression, anxiety and interpersonal conflicts, SU

Physiological problems Increased stress = compromised immune health

Suboptimal adherence to antiretroviral therapy (ART) (ART avoidance behaviors that result in poor adherence to ART regimens)

ART and Stigma

Despite the importance of HIV medication adherence for effective treatment of HIV, population-based estimates in the United States (US) indicate suboptimal levels of adherence to antiretroviral therapy (ART) (8) 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

Case Studies

Psychology team was consulted by medical team to meet with the following patient due to nonadherence with HAART: 24 year-old Black American female Vertically acquired HIV Diagnosed with Persistent Depression Also meets criteria for PTSD, related to HIV dx Extensive history of nonadherence to HAART Through counseling sessions it was explored that the patient

“forgets” medications

Case Studies

During a routine screening by the psychology team at the medical clinic, the following patient was evaluated: 49 year-old, White Hispanic, female s/p HIV dx in 2007 Admitted to occasional trouble remembering her medications Patient appeared unable or unwilling to disclose how she

acquired HIV by stating that she has “always had a bad immune system” and that she once had “shingles”

Endorsed being divorced but requested to be labeled as “single”

What to do?

There needs to be an integrated approach to be able to address HIV related stigma (10):

Individual level Increasing individual knowledge about HIV transmission, prevention and care, as well as access to services and

legal rights is important

Interpersonal level Assist with increasing social support

Ex: We Are Family campaign from Greater Than AIDS reinforces the importance of social support for PLWH. Organizational level

Healthcare providers are often named by PLWH as important sources of stigma. Programs for training healthcare workers should address culturally-specific stigma drivers, including personal fears of infection, prejudice towards vulnerable groups, and misconceptions or lack of knowledge about HIV transmission, prevention, treatment and universal precautions

Programs also should address how the effect of stigma, discrimination, breaches of confidentiality and negative attitudes can negatively impact patients’ lives, health, and ability to follow treatment regimens

Biomedical and behavioral approaches to HIV prevention, such as PrEP, routine HIV testing, starting treatment soon after diagnosis (test and treat), and treatment for PLWH to viral suppression, have been successful in the US and several countries in reducing new HIV infections and improving the life and health of PLWH.

However, HIV stigma and discrimination can greatly impact the success of these interventions Stigma surrounding PrEP use, including assumptions about promiscuity, can negatively affect PrEP access and uptake

Prejudice among healthcare workers may result in drug users, young adults, women and other marginalized populations not being offered either PrEP or HIV testing.

What to do?

Become informed to be able to inform

Reduction of HIV-related stigma and discrimination http://www.unaids.org/en/resources/documents/2014/ReductionofHIV-

relatedstigmaanddiscrimination Developing a Stigma Reduction Initiative

SAMHSA toolkit provides tools to reduce negative public perceptions related to mental health. It covers planning, collaboration development, outreach to schools and businesses, marketing, and grassroots outreach.

https://store.samhsa.gov/product/Developing-a-Stigma-Reduction-Initiative-with-CD-/SMA06-4176

Assessment Ex: Berger HIV Stigma Scale

Treatment Evidence based practice

Individual vs group therapy Psychiatry (if warranted due to psychiatric symptoms)

References

1. UNAIDS (2015) ‘On the Fast-Track to end AIDS by 2030: Focus on location and population’2. Earnshaw, V. A., Lang, S. M., Lippitt, M., Jin, H., & Chaudoir, S. R. (2015). HIV stigma and physical health

symptoms: Do social support, adaptive coping, and/or identity centrality act as resilience resources?. AIDS and Behavior, 19(1), 41-49.

3. Earnshaw, V. A., Smith, L. R., Chaudoir, S. R., Amico, K. R., & Copenhaver, M. M. (2013). HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS and Behavior, 17(5), 1785-1795.

4. Weiss, S. M., Tobin, J. N., Antoni, M., Ironson, G., Ishii, M., Vaughn, A., ... & LaPerriere, A. (2011). Enhancing the health of women living with HIV: the SMART/EST Women’s Project. International journal of women's health, 3, 63.

5. Turan, B., Smith, W., Cohen, M. H., Wilson, T. E., Adimora, A. A., Merenstein, D., ... & Tien, P. C. (2016). Mechanisms for the Negative Effects of Internalized HIV-Related Stigma on Antiretroviral TherapyAdherence in Women: The Mediating Roles of Social Isolation and Depression. Journal of acquiredimmune deficiency syndromes (1999), 72(2), 198.

6. McCoy, K., Higgins, M., Zuñiga, J. A., & Holstad, M. M. (2015). Age, Stigma, Adherence and Clinical Indicators in HIV-Infected Women. HIV/AIDS research and treatment: open journal, 2015(SE3), S1.

7. Brown, M. J., Serovich, J. M., Kimberly, J. A., & Hu, J. (2016). Psychological reactance and HIV-related stigma among women living with HIV. AIDS care, 28(6), 745-749.8.

10. CDC. Let’s Stop HIV Together. www.cdc.gov/actagainstaids/campaigns/lsht/11. Berger, B. E., Ferrans, C. E., & Lashley, F. R. (2001). Measuring stigma in people with HIV: Psychometric

assessment of the HIV stigma scale¶. Research in nursing & health, 24(6), 518-529.