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A Multifaceted Strategy to Reduce HIV-Related Stigma and Disparities
Social determinants of health are defined as the conditions in which people are born, grow, work, live, and age, as well as the wider set of forces and systems shaping the conditions of daily life.1 The 40-year HIV epidemic, in addition to the more recent COVID19 pandemic, has produced data that these factors have a role in the transmission, morbidity, and mortality of infectious diseases.1 New data emerged regarding the effect of social determinants on patient outcomes and several disease states. However, disparities have long been known to harm people with HIV. HIV-related stigma also is associated with several adverse outcomes.2 HIV transmission is related to local HIV prevalence, individual behaviors, biological factors, and social conditions.3 Disparities are found in HIV transmission, access to treatment, and disease course. It is imperative to consider that disease is influenced by community, societal, and environmental factors.1
As part of HIV treatment, adherence to treatment and the ability to achieve undetectable HIV RNA is affected by HIV-related stigma.2 Many advances have been made in HIV treatment and prevention; however, not all people with HIV have access to the same treatment and some individuals cannot adhere to treatment for various reasons. Social support, specifically tangible support networks, is critical for linkage to care and antiretroviral therapy (ART) adherence.4 Limited health literacy also affects the relationship between the patient’s race and ART adherence. Health literacy is a modifiable factor; patient materials should be written at an appropriate reading level.5 This particular disparity may be reduced by improving patient education materials and using more suitable communication modes. Positive reinforcement and an expression of thanks for keeping appointments may foster adherence success.6
Stigma is additionally related to the fear of discrimination and rejection by healthcare service providers. This discrimination may lead to medical mistrust, resulting in a vicious cycle of disparity.4 People who are transgender experience health disparities and discrimination across the HIV continuum of care. A case-control study compared transgender women with HIV with cisgender women and cisgender men with HIV.4 Measures of the HIV treatment cascade and correlates of HIVrelated health status (eg, depression, stress, drug use, medical mistrust, emotional and tangible social support) were assessed. Transgender women were significantly less likely to receive
and be adherent to ART, leading to lower HIV RNA suppression than in cisgender individuals.4 In a multivariate model, transgender women having less tangible social support predicted health disparities.
Poor engagement in care and delayed initiation of ART have personal and public health consequences. Systematic monitoring of engagement in care allows an opportunity to follow up on missed visits and re-engage people with HIV.6 Shared decision making, especially about choice of ART, will provide a sense of empowerment and autonomy over healthcare decisions.6
Stigma and disparities related to HIV also can lead to mental health conditions. There is a clear link between environmental stress, stigma, and psychological issues.3 Stress and stigma affect health behaviors, including accessing care. Premorbid depression and trauma have been shown to influence HIV disease progression.3 The multifactorial aspects of mental health and HIV lead to disparities in health outcomes. Appropriate identification of potential mental health issues and linkage to mental health services, if applicable, should be considered in all people with HIV, especially those with an existing history of psychiatric illness.6
A systematic review and meta-analysis of sociodemographic, clinical, and service use determinants associated with stigma among people with HIV/AIDS found several risk factors for self-reported stigma.2 This study was unique in that it included clinical, demographic, and health services use in the analysis. This analysis involved 31 studies published before November 2020 and represented 10,475 participants.2 The study found significant protective associations between selfreported stigma and age older than 30 years, living with a spouse, having a CD4 T-lymphocyte count of less than 200 cells/mcL, ART adherence, time since HIV diagnosis, and accessibility to HIV care.2
Health disparities lead to differences in the cascade of care for adolescents and young adults with HIV compared with older adults who have HIV.7 Specific transitions of care in this population introduce barriers, such as changing care providers and loss of access to social support with adult services. Youth-friendly services, including office hours, staff, and physical space, should be considered to remove obstacles to adherence.6 Gender-affirming and behavioral healthcare should be integrated with HIV care when possible.
Appropriate messaging about HIV is needed to provide updated information on ending the HIV epidemic and reducing HIV transmission.8 Public health messaging has evolved with the epidemic. Currently, the message is that prevention and treatment could end the HIV epidemic in the United States. In addition, health equity in HIV communications should consider social and structural inequalities and focus on social justice.8 Stigma should be called out and communications should be empowering.
Intentional interventions are needed to begin the elimination of disparities for people with HIV. Healthcare services should address the needs and preferences of diverse populations. Barriers to literacy and communication should be targeted and reduced to facilitate appropriate patient care. Additionally, researchers should include racial, ethnic, religious, and gender minority groups in clinical trials by removing obstacles to participation and reducing stigma.
References
1. Hogan JW, Galai N, Davis WW. Modeling the impact of social determinants of health on HIV. AIDS Behav. 2021; 25(suppl 2):215-224.
2. Armoon B, Higgs P, Fleury MJ, et al.
Socio-demographic, clinical and service use determinants associated with
HIV related stigma among people living with HIV/AIDS: a systematic review and meta-analysis. BMC Health Serv Res. 2021;21(1):1004.
3. Pellowski JA, Kalichman SC, Matthews KA.
A pandemic of the poor: social disadvantage and the U.S. HIV epidemic.
Am Psychol. 2013;68(4):197-209.
4. Kalichman SC, Hernandez D, Finneran S.
Transgender women and HIV-related health disparities: falling off the
HIV treatment cascade. Sex Health. 2017;14(5):469-476.
5. Osborn CY, Paasche-Orlow MK, Davis TC.
Health literacy: an overlooked factor in understanding HIV health disparities.
Am J Prev Med. 2007;33(5):374-378.
6. Department of Health and Human Services. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV.
Accessed March 1, 2022. https://bit. ly/3oAt4xN-IDSE
7. Zanoni BC, Mayer KH. The adolescent and young adult HIV cascade of care in the United States: exaggerated health disparities. AIDS Patient Care STDS. 2014;28(3):128-135.
8. Taggart T, Ritchwood TD, Nyhan K.
Messaging matters: Achieving equity in the HIV response through public health communication. Lancet HIV. 2021;8(6):e376-e386.
AAHIVP, FCCP, is an associate professor, College of Pharmacy, Midwestern University, in Downers Grove, Illinois.
