Exploring the Mediating Role of Tobacco Use in the Relationship between Gender Discrimination, Racial Discrimination, HIV-Related Stigma and HIV Clinical Outcomes Among Women Living with HIV in Canada

Background and Purpose: HIV-related stigma, racial discrimination, and gender discrimination converge to elevate HIV vulnerabilities among women while simultaneously constraining access to HIV prevention and care services. The intersection of these multiple forms of stigma is referred to as ‘intersectional stigma’ that harms women living with HIV’s (WLHIV) health and wellbeing. Coping strategies such as tobacco use may reduce chronic stigma-related stressors. Yet there are serious adverse health effects associated with long term tobacco use among WLHIV. These include poorer viral responses to antiretroviral therapy (ART), increased morbidity, and pregnancy loss. Limited research has explored intersectional stigma and tobacco use. We examined coping strategies (tobacco use, resilience) as mediators of the relationship between intersectional stigma (HIV-related stigma, gender discrimination, racial discrimination) and HIV clinical outcomes among WLHIV in Canada.

Methods: We conducted a community-based national cohort study involving a cross-sectional survey with WLHIV in three Canadian provinces. Structural equation modeling (SEM) using weighted least squares estimation methods was used to test the direct effects of intersectional forms of stigma (HIV-related stigma, gender discrimination, racial discrimination) on HIV-related clinical outcomes (>90% ART adherence, CD4 count >200 cells/mm3, undetectable viral load), and the indirect effects via resilience and current tobacco use, adjusting for socio-demographic factors. We used validated measures for HIV-related stigma (shortened HIV Stigma Scale), racial/gender discrimination (Everyday Discrimination Scale), and resilience (Resiliency Scale). Tobacco use (current, former but not current, never) and HIV outcomes were self-reported.

Results: Among 1422 participants (median age: 42.5 years; IQR=35-50), most were women of color (29.40% African, Caribbean and Black; 22.36% Indigenous; 7.17% other ethnicities; 41.07% white). Over one-third (43.66%; n=616) currently used tobacco, 12.05% (n=170) formerly used, and 44.29% (n=624) had never used tobacco. SEM results suggest that racial discrimination had a direct effect on ART adherence (B=-0.215, p<0.001: direct effect; B=0.046, p<0.01: indirect effect), resilience partially mediated this relationship. Current tobacco use fully mediated the relationship between gender discrimination and lower CD4 count (B=-0.061, p<0.01) and detectable viral load (B=-0.055, p<0.01). Current tobacco use partially mediated the relationship between gender discrimination and ART adherence (B=-0.044, p<0.01). Resilience fully mediated the relationship between HIV-related stigma (B=0.040, p<0.01) and racial discrimination (B=0.027, p<0.01) with CD4 count, and between HIV-related stigma (B=0.021, p<0.05) and racial discrimination (B=0.014, p<0.05) with viral load. Fit indices suggest good model fit (CFI=0.937; RMSEA=0.048 [90% CI: 0.43-0.069]; SRMR=0.030).

Conclusions and Implications: Intersectional stigma based on HIV, racial and gender inequities contributed to increased tobacco use and reduced resilience among WLHIV, that in turn contributed to lower CD4 count and detectable viral load. These findings signal the importance of identifying social determinants of tobacco use, such as intersectional stigma, among WLHW. There is an urgent need for intersectional stigma reduction interventions that tackle ongoing racial, gender and HIV bias at institutional (e.g. healthcare, employment), community (e.g. community norms), and individual (e.g. resilience, adaptive coping) levels. Tobacco cessation strategies can be tailored to bolster resilient coping and address the unique stressors among WLHIV who use tobacco as an intersectional stigma coping strategy.