Racial, Gender and HIV-Related Stigma and Discrimination: Exploring Pathways to Quality of Life Among a National Cohort of Women Living with HIV in Canada

Background and Purpose: Social inequities compromise quality of life among women with HIV. While associations between HIV-related stigma and poor physical and mental health-related quality of life (HRQoL) are well established, less is known about experiences and health impacts of intersecting stigma and discrimination based on race and gender among women with HIV. There are also knowledge gaps regarding structural (e.g., economic insecurity) and interpersonal (e.g., social support) factors that may mediate relationships between intersecting stigma and HRQoL. Such factors may be particularly amenable to social work intervention. Our objective was to test a conceptual model of pathways between intersecting stigmas (HIV-related, racial, gender) and physical and mental HRQoL among women with HIV in Canada.

Methods: We utilized baseline survey data from a national cohort of women with HIV in Canada (n=1425). We drew on standardized measures of HIV-related stigma (Wright’s HIV Stigma Scale), racial discrimination (Everyday Discrimination Scale – Racism), gender discrimination (Everyday Discrimination Scale – Sexism), physical and mental health-related quality of life (SF-12), social support (MOS-SSS), and a latent construct of economic insecurity comprised of housing and food insecurity. Structural equation modeling was conducted using maximum likelihood estimation methods to test the direct effects of HIV-related stigma, racial discrimination and gender discrimination on mental and physical HRQoL and the indirect effects via low social support and economic insecurity, adjusting for socio-demographic factors. We hypothesized that intersecting stigma would directly affect HRQoL, and that social support and economic insecurity would mediate this relationship.

Results: Participant median age was 43 years (IQR=35-50); most participants were women of color (29% African, Caribbean and Black; 22% Indigenous; 7% other ethnicities; 41% white). Approximately two thirds (65%) of participants reported an annual household income below the poverty line (CA $20,000); over half experienced food insecurity (64%) and housing insecurity (51%). HIV-related stigma (B= -0.09, p<0.001) and gender discrimination (B=-0.20, p<0.001) had significant direct effects on mental HRQoL.  Economic insecurity mediated the relationship between HIV-related stigma and physical HRQoL (B= -0.008, p<0.05), racial discrimination and physical HRQoL (B= -0.035, p<0.01), and racial discrimination and mental HRQoL (B= -0.020, p<0.05). Social support partially mediated the relationship between HIV-related stigma and mental HRQoL (B= -0.029, p<0.001) and gender discrimination and mental HRQoL (B= -0.068, p<0.01). Model fit indices suggest good model fit (χ²[1] =3.319, P=0.069; CFI=0.998; RMSEA=0.042; SRMR=0.004).

Conclusions and Implications: Findings suggest that intersecting stigma (HIV-related, gender, racial) influences physical and mental health-related quality of life among women with HIV through different pathways. Interventions to reduce HIV-related stigma, racial and gender discrimination in healthcare and community settings are urgently needed. In addition to directly challenging intersecting stigma, social workers can advocate to address food and housing insecurity among women with HIV to reduce the harmful impacts of HIV-related stigma and racial discrimination on physical health. Social workers can collaboratively develop economic security and social support programs to mitigate the deleterious impacts of HIV-related stigma and gender discrimination on mental health. Findings can inform multi-level interventions to optimize health, wellbeing and equity among women with HIV.