The Association of Internalized and Enacted HIV Stigma with Medication Adherence, Mental Health, and Adherence Skills in Young People Living with HIV in Zambia

Background: Stigma is a well-documented factor negatively affecting outcomes across the HIV care continuum. Among young people living with HIV (YPLH), stigma is a barrier to testing, treatment initiation, and engagement in care. While prior studies have shown consistent association between stigma and HIV treatment, few studies have examined whether association differs by type of stigma mechanisms experienced by YPLH. Even fewer are studies that have investigated whether HIV stigma mechanisms are differentially associated with adherence-related skills and mental health outcomes in YPLH. This study examined the differential association of two individual-level HIV stigma mechanisms (internalized and enacted) with treatment adherence, mental health, and adherence-related skills among YPLH in Zambia.

Methods: Cross-sectional data were obtained from a sample of YPLH (N = 120) in Eastern Province, Zambia. Medication adherence was measured using a visual analog scale and the CASE adherence index. Mental health outcomes included depression symptoms and self- esteem. Adherence skills referred to adherence-related motivation and behavioral skills. Internalized stigma referred to endorsement of negative feelings and beliefs associated with HIV and applying them to the self, whereas enacted stigma referred to experiences of discrimination, stereotyping, and/or prejudice because of one’s HIV. Stigma was measured using the HIV and AIDS Stigma Instrument (Holzemer et al., 2007). Analyses were conducted using linear and logistic regression methods, after missing data were imputed using multiple imputation by chained equations.

Results: Sixty three percent of participants were female; 62% were enrolled in school at the time of data collection. Mean age was 19 years old. Internalized stigma was consistently and negatively associated with medication adherence, mental health, and adherence skills. Greater internalized stigma was associated with lower likelihood of treatment adherence (O.R. = 0.70, 95% CI: 0.50, 0.91), lower adherence-related motivation (β = -0.60, 95% CI: -0.84, -0.35) and behavioral skills (β = -0.81, 95% CI: -1.22, -0.40), lower self-esteem (β = 0.51, 95% CI: 0.19, 0.82), and severe depression symptoms (β = 0.24, 95% CI: 0.08, 0.41). Enacted stigma was not significantly associated with adherence, mental health, or adherence skills.

Implications: Study findings support a differential association of HIV stigma mechanisms with health outcomes. Higher levels of internalized stigma appears to be a robust predictor of poor adherence, adverse mental health, and low adherence skills in our sample of Zambian YPLH, whereas enacted stigma’s association with health outcomes is inconclusive. Our findings confirm that internalized HIV stigma may have particularly strong associations with affective and behavioral indicators of health. Unlike enacted stigma which involves experiences with others, internalized stigma may exemplify YPLH’s inner struggle to make sense of previously held negative feelings about HIV and their own HIV positive status. Youth-focused skills-building programs for YPLH might be needed, or other programs could be adapted, to mitigate the negative association of a specific (internalized) stigma mechanism.