A moderated mediation analysis of HIV and intersectional stigmas and antiretroviral adherence in people living with HIV in the Dominican Republic

Abstract

Experiencing HIV and intersectional stigmas in healthcare settings may affect antiretroviral treatment (ART) adherence among people with HIV (PWH), given their need for frequent interactions with clinical settings and healthcare providers. Considering the importance of reducing stigmas to promote well-being and the need to elucidate how stigma influences health across various settings, we examined how experienced HIV stigma in Dominican Republic healthcare settings impacts ART adherence through internalized HIV stigma and whether race or sexual orientation stigma moderates this relationship. Participants were 471 PWH (aged 17-71) who were recruited from two HIV clinics in the Dominican Republic in 2021-2022. Results revealed a significant mediation effect (B=-0.10, SE = 0.05, CI [-0.234, - 0.014]) after adjusting for effect of age and time since HIV diagnosis, suggesting that experienced HIV stigma in healthcare settings was associated with more internalized HIV stigma (B = 0.39, SE = 0.11, p = .001), subsequently linked to lower ART adherence (B=-0.26, SE = 0.11, p = .016). The indirect effect was significant at low levels of race stigma (B=-0.16, SE = 0.09, CI [-0.369, - 0.001]) but not at high levels of race stigma (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). This indirect effect was also significant at low levels of sexual orientation stigma (B=-0.19, SE = 0.10, CI [-0.401, - 0.023]) but not at high levels of sexual orientation stigma (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). These findings suggest that addressing experienced HIV stigma in Dominican Republic healthcare settings, along with various dimensions of HIV-related stigma (e.g., internalized stigma) and intersecting stigmas (e.g., race, sexual orientation), is vital for improving health outcomes, such as optimal ART adherence. Experimentar estigmas relacionados con el VIH e interseccionales en entornos de atenci & oacute;n m & eacute;dica puede afectar la adherencia al tratamiento antirretroviral (TAR) entre las personas que viven con VIH (PVVIH), dado que necesitan interacciones frecuentes con entornos cl & iacute;nicos y proveedores de atenci & oacute;n m & eacute;dica. Considerando la importancia de reducir los estigmas para promover el bienestar y la necesidad de esclarecer c & oacute;mo el estigma influye en la salud en diversos contextos, examinamos c & oacute;mo el estigma del VIH experimentado en entornos de atenci & oacute;n m & eacute;dica en la Rep & uacute;blica Dominicana impacta la adherencia al TAR a trav & eacute;s del estigma internalizado del VIH y si el estigma racial o de orientaci & oacute;n sexual modera esta relaci & oacute;n. Los participantes fueron 471 PVVIH (de 17 a 71 a & ntilde;os) que fueron reclutados de dos cl & iacute;nicas de VIH en la Rep & uacute;blica Dominicana en 2021-2022. Los resultados revelaron un efecto de mediaci & oacute;n significativo (B=-0.10, SE = 0.05, CI [-0.234, - 0.014]) despu & eacute;s de ajustar por el efecto de la edad y el tiempo desde el diagn & oacute;stico de VIH, sugiriendo que el estigma del VIH experimentado en entornos de atenci & oacute;n m & eacute;dica estaba asociado con un mayor estigma internalizado del VIH (B = 0.39, SE = 0.11, p = .001), vinculado posteriormente a una menor adherencia al TAR (B=-0.26, SE = 0.11, p = .016). El efecto indirecto fue significativo en niveles bajos de estigma racial (B=-0.16, SE = 0.09, CI [-0.369, - 0.001]) pero no en niveles altos de estigma racial (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). Este efecto indirecto tambi & eacute;n fue significativo en niveles bajos de estigma por orientaci & oacute;n sexual (B=-0.19, SE = 0.10, CI [-0.401, - 0.023]) pero no en niveles altos de estigma por orientaci & oacute;n sexual (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). Estos hallazgos sugieren que abordar el estigma del VIH experimentado en entornos de atenci & oacute;n m & eacute;dica en la Rep & uacute;blica Dominicana, junto con diversas dimensiones del estigma relacionado con el VIH (por ejemplo, estigma internalizado) y estigmas interseccionales (por ejemplo, raza, orientaci & oacute;n sexual), es vital para mejorar los resultados de salud, como la adherencia & oacute;ptima al TAR.