This Week in HIV Research: The Clinical Impacts of Stigma

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We've long been aware of the deeply pervasive relationship between stigma and the persistence of the HIV epidemic. What's been covered less, until relatively recently, is the effect of HIV-related stigma on measurable clinical outcomes.

Much of the research we present in this week's summary of newly published HIV-related science focuses on this critical intersection of mental/social health and physical health -- and points to the extent to which this relationship is exacerbated among women and people of color. For instance, we learn about new data that:

  • Highlight the low levels of viral suppression among HIV-positive women in the U.S. who are black or under the age of 25.
  • Point to how discrimination and medical system distrust negatively affect HIV treatment adherence among women.
  • Note the commonality of generalized anxiety disorder among people living with HIV, especially women.
  • Find an association between depression and impaired executive function in people with HIV -- again, especially women.

Let's explore these important intersectional findings in more detail. To beat HIV, you have to follow the science!

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Viral Suppression Lowest Among Black, Young U.S. Women

Women who are black or under the age of 25 are the least likely groups of women living with HIV to achieve viral suppression, an analysis of 2015 and 2016 data from 40 U.S. jurisdictions published in the Journal of Acquired Immune Deficiency Syndromes found.

On the one hand, they study showed that 76% of the 6,407 women diagnosed with HIV in the 40 U.S. jurisdictions in 2016 had been linked to care within one month of diagnosis, and 85% had been linked to care within three months. On the other hand, only 58% of all HIV-positive women in those 40 jurisdictions who were known to be living with HIV in 2015 were categorized as "retained in care" that year (defined as receiving two or more CD4 or viral load tests at a minimum interval of three months), and the same percentage had a most recent viral load test result below 200 copies/mL. Linkage to care rates were similar across racial/ethnic groups, but retention and viral suppression rates were not. They were highest among Latinas (62% retention, 62% viral suppression), followed by white women (54% retention but 60% viral suppression) and black women (56% retention, 56% viral suppression).

Viral suppression rates increased with age, but remained lower among black women than among Latinas or white women in each age group, with the lowest rate (44%) observed among black women aged 13 to 24. Those living in the U.S. South also had especially low viral suppression rates: 55%, compared to 57% in midwestern states, 61% in western states, and 62% in northeastern states.

Researchers cited other studies showing lower HIV treatment adherence among young people and suggested interventions that involve family members of young women living with HIV. After offering a reminder that black women face social and structural barriers, the authors recommended stigma reduction and enhanced support services for this group.

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Discrimination and Distrust Negatively Affect Adherence Among Women

Everyday discrimination, group-based medical distrust, and internalized stigma hamper HIV treatment adherence and engagement in care among women in North Carolina, a small study published in the Journal of Acquired Immune Deficiency Syndromes showed. These issues were mediated by depressive symptoms, but not by age per se.

Researchers analyzed baseline and screening data on 123 participants -- 33 of whom were 50 or more years old and 76% of whom were black -- enrolled in the Women's Interagency HIV Study (WIHS) at a single site. While age did not mediate the pathways between the various forms of discrimination, stigma, and distrust, it did affect internalized stigma and quality of life.

Study authors noted that people who distrust health care may be less likely to enroll in studies such as WIHS, potentially limiting the study results. "Interventions are needed to combat these important contextual factors and their clinical and psychosocial effects on the lives of [women living with HIV]," they concluded.

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Generalized Anxiety Disorder More Common Among People Living With HIV

Another reason a person may experience difficulties with treatment adherence and retention in care is generalized anxiety disorder (GAD), which is significantly more prevalent among people living with HIV than among the general population, a study published in AIDS found.

Based on Medical Monitoring Project data from 3,654 people living with HIV, study authors estimated a 19% prevalence rate for GAD symptoms in this population. By comparison, less than 3% of the general U.S. population is estimated to suffer from the disorder.

HIV-positive people with anxiety symptoms were found to be more likely to engage in behaviors that put them at risk of transmitting HIV. They also visited emergency rooms more often than people living with HIV who did not exhibit symptoms of anxiety. GAD was associated with social determinants of health, such as homelessness, as well as experiences of intimate partner and sexual violence. As in the general population, anxiety often co-occurred with depression; the latter has been shown to reduce treatment adherence and engagement in care.

"Incorporating routine screening for GAD in HIV clinical settings may help improve health outcomes, reduce HIV transmission, and save health care costs," the study authors concluded.

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Executive Function More Impaired Among Depressed Women Than Men

Among those with depression, some executive function is impaired in women living with HIV at three times the rate of men living with HIV, a study published in the Journal of Acquired Immune Deficiency Syndromes showed. The study also found that such impairment was five times more common among HIV-positive women than HIV-negative women.

Researchers had 858 PLWH and 562 HIV-negative people living in the U.S. complete depression assessments, as well as tests measuring executive function, psychomotor speed, and motor function. Half of each group were women. Men were drawn from the MACS study, which includes only gay or bisexual men, while women came from the WIHS study, which includes mostly heterosexual women.

The researchers found that, among people living with HIV, more men than women showed depressive symptoms -- a relationship different from that seen in the general population. Other studies have shown that sexual minorities experience depression at greater rates, which might explain this result, study authors noted.

Independent of HIV status, depressed participants performed worse on executive function tests than those without depressive symptoms.

Study authors hypothesized that biological mechanisms -- or men's better access to mental health services -- may explain the sex difference observed among those living with HIV. They called for better psychological and psychiatric services for both men and women living with HIV.

This paper is the final, published version of a study that was initially presented at CROI 2019 and published ahead of print in March.