Abstract
Internalized HIV stigma can affect health outcomes, but the mechanism underlying this relationship is poorly understood. We investigated the potential pathways for the association between internalized stigma and opportunistic infections (OIs) among women living with HIV in rural India. We conducted a cross-sectional study involving in-person interviews with 600 participants. We modeled two outcome variables, total number of OIs and fungal dermatoses, which was the most frequently reported OI. Causal mediation analysis was performed to estimate the total effect, direct effect, and indirect effect through mediators while controlling for confounders. Food insecurity was a strong mediator of the association between internalized stigma and the number of OIs (70% of the total effect) and fungal dermatoses (83% of the total effect), while the indirect effect of stigma through adherence was minimal for both outcomes. Household food insecurity may be an important mediator of the impact of HIV-related stigma on opportunistic infections.
Similar content being viewed by others
References
Rueda S, Mitra S, Chen S, Gogolishvili D, Globerman J, Chambers L, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses. BMJ Open. 2016;6(7):e011453.
Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser SD, Bangsberg DR, et al. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc. 2013;16(3):18640.
Turan B, Hatcher AM, Weiser SD, Johnson MO, Rice WS, Turan JM. Framing mechanisms linking HIV-related stigma, adherence to treatment, and health outcomes. Am J Public Health. 2017;107(6):863–9.
Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health. 2013;103(5):813–21.
Turan B, Smith W, Cohen MH, Wilson TE, Adimora AA, Merenstein D, et al. Mechanisms for the negative effects of internalized HIV-related stigma on antiretroviral therapy adherence in women: the mediating roles of social isolation and depression. J Acquir Immune Defic Syndr. 2016;72(2):198–205.
Pascoe EA, Richman LS. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135(4):531–54.
Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007;298(14):1685–7.
Kemeny ME. Psychobiological responses to social threat: evolution of a psychological model in psychoneuroimmunology. Brain Behav Immun. 2009;23(1):1–9.
Ramjee G, Daniels B. Women and HIV in Sub-Saharan Africa. AIDS Res Ther. 2013;13(10):30.
Akena D, Musisi S, Joska J, Stein DJ. The association between aids related stigma and major depressive disorder among HIV-positive individuals in Uganda. PLoS ONE. 2012;7(11):e48671.
Poundstone KE, Strathdee SA, Celentano DD. The social epidemiology of human immunodeficiency virus/acquired immunodeficiency syndrome. Epidemiol Rev. 2004;26(1):22–35.
Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav. 2002;6(4):309–19.
Crandall CS, Coleman R. AIDS-related stigmatization and the disruption of social relationships. J Soc Pers Relatsh. 1992;9(2):163–77.
Fife BL, Wright ER. The dimensionality of stigma: a comparison of its impact on the self of persons with HIV/AIDS and cancer. J Health Soc Behav. 2000;41(1):50.
Malavé S, Ramakrishna J, Heylen E, Bharat S, Ekstrand ML. Differences in testing, stigma, and perceived consequences of stigmatization among heterosexual men and women living with HIV in Bengaluru, India. AIDS Care. 2014;26(3):396–403.
Amin A. Addressing gender inequalities to improve the sexual and reproductive health and wellbeing of women living with HIV. J Int AIDS Soc. 2015;18((6S5)):20302.
Tsai AC, Bangsberg DR, Emenyonu N, Senkungu JK, Martin JN, Weiser SD. The social context of food insecurity among persons living with HIV/AIDS in rural Uganda. Soc Sci Med. 2011;73(12):1717–24.
Danziger R. The social impact of HIV/AIDS in developing countries. Soc Sci Med. 1994;39(7):905–17.
Weiser SD, Young SL, Cohen CR, Kushel MB, Tsai AC, Tien PC, et al. Conceptual framework for understanding the bidirectional links between food insecurity and HIV/AIDS. Am J Clin Nutr. 2011;94(6):1729S–39S.
Ivers LC, Cullen KA, Freedberg KA, Block S, Coates J, Webb P, et al. HIV/AIDS, undernutrition, and food insecurity. Clin Infect Dis. 2009;49(7):1096–102.
Koethe JR, Heimburger DC, PrayGod G, Filteau S. From wasting to obesity: the contribution of nutritional status to immune activation in HIV infection. J Infect Dis. 2016;214((suppl 2)):S75–82.
Faintuch J, Soeters PB, Osmo HG. Nutritional and metabolic abnormalities in pre-AIDS HIV infection. Nutrition. 2006;22(6):683–90.
Chlebowski RT, Grosvenor MB, Bernhard NH, Morales LS, Bulcavage LM. Nutritional status, gastrointestinal dysfunction, and survival in patients with AIDS. Am J Gastroenterol. 1989;84(10):1288–93.
Wheeler DA. Weight loss and disease progression in HIV infection. AIDS Read. 1999;9(5):347–53.
Nagata JM, Fiorella KJ, Salmen CR, Hickey MD, Mattah B, Magerenge R, et al. Around the table: food insecurity, socioeconomic status, and instrumental social support among women living in a rural Kenyan Island Community. Ecol Food Nutr. 2015;54(4):358–69.
Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539–45.
Nyamathi A, Ekstrand M, Heylen E, Ramakrishna P, Yadav K, Sinha S, et al. Relationships among adherence and physical and mental health among women living with HIV in rural India. AIDS Behav. 2016. https://doi.org/10.1007/s10461-016-1631-3.
Heravian A, Solomon R, Krishnan G, Vasudevan CK, Krishnan AK, Osmand T, et al. Alcohol consumption patterns and sexual risk behavior among female sex workers in two South Indian communities. Int J Drug Policy. 2012;23(6):498–504.
Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, Wrubel J, et al. HIV-related stigma: adapting a theoretical framework for use in India. Soc Sci Med. 2008;67(8):1225–35.
Ekstrand ML, Ramakrishna J, Bharat S, Heylen E. Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions. J Int AIDS Soc. 2013;16((3Suppl 2)):18717.
Coates J, Swindale A, Bilinsky P. Household food insecurity access scale (HFIAS) for measurement of food access: indicator guide. Washington, DC: Academy for Educational Development; 2007. https://www.fantaproject.org/monitoring-and-evaluation/household-food-insecurity-access-scale-hfias.
Giordano TP, Guzman D, Clark R, Charlebois ED, Bangsberg DR. Measuring adherence to antiretroviral therapy in a diverse population using a visual analogue scale. HIV Clin Trials. 2004;5(2):74–9.
Ekstrand ML, Chandy S, Heylen E, Steward W, Singh G. Developing useful HAART adherence measures for India: the prerana study. J Acquir Immune Defic Syndr (1999). 2010;53(3):415–6.
Ekstrand ML, Shet A, Chandy S, Singh G, Shamsundar R, Madhavan V, et al. Suboptimal adherence associated with virological failure and resistance mutations to first-line highly active antiretroviral therapy (HAART) in Bangalore, India. Int Health. 2011;3(1):27–34.
Wasserstein RL, Lazar NA. The ASA’s Statement on p-values: context, process, and purpose. Am Stat. 2016;70(2):129–33.
Greenland S, Senn SJ, Rothman KJ, Carlin JB, Poole C, Goodman SN, et al. Statistical tests, P values, confidence intervals, and power: a guide to misinterpretations. Eur J Epidemiol. 2016;31(4):337–50.
Robins JM, Greenland S. Identifiability and exchangeability for direct and indirect effects. Epidemiology. 1992;3(2):143–55.
Yu Q, Fan Y, Wu X. General multiple mediation analysis with an application to explore racial disparities in breast cancer survival. J Biom Biostat. 2014;5:189.
Yu Q, Li B. mma: an R package for mediation analysis with multiple mediators. J Open Res Softw. 2017;5(1):11.
Tsai AC, Bangsberg DR, Frongillo EA, Hunt PW, Muzoora C, Martin JN, et al. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Soc Sci Med. 2012;74(12):2012–9.
Hong SY, Fanelli TJ, Jonas A, Gweshe J, Tjituka F, Sheehan HMB, et al. Household food insecurity associated with antiretroviral therapy adherence among HIV-infected patients in Windhoek, Namibia. J Acquir Immune Defic Syndr. 2014;67(4):E115–22.
Acknowledgements
We are thankful to the study participants who made this study possible. The authors acknowledge the following sources of support: National Institute of Mental Health (NIMH) R01MH098728 and the National Institute of Allergy and Infectious Diseases K01AI118559.
Funding
This study was funded by the National Institute of Mental Health (R01MH098728) and the National Institute of Allergy and Infectious Diseases (K01AI118559) of the U.S. National Institutes of Health (NIH).
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
All procedures in this study were conducted in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments. This study was approved by the University of California Los Angeles Institutional Review Board, University of California Irvine Institutional Review Board, and the Ministry of Health Research Ethics Committee in India.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Shin, S.S., Carpenter, C.L., Ekstrand, M.L. et al. Household Food Insecurity as Mediator of the Association Between Internalized Stigma and Opportunistic Infections. AIDS Behav 22, 3897–3904 (2018). https://doi.org/10.1007/s10461-018-2193-3
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10461-018-2193-3