Research has shown that prompt initiation of care after HIV diagnosis is critical to reduce mortality and viral transmission by lowering viral load early during disease progression. These interventions are especially important in communities where HIV is endemic; however, it is not clear how psychosocial factors related to HIV stigma and coping are associated with HIV care utilization after an HIV diagnosis. A recent study headed by Dr. Yamilé Molina (Center for Research on Women and Gender, University of Illinois at Chicago; formerly of the Thompson group, Public Health Sciences) and Dr. Angela Ulrich (University of Minnesota; formerly of the Duerr group, Vaccine and Infectious Disease Division) published in AIDS Care investigated whether pre-diagnosis HIV stigma awareness and maladaptive coping strategies predicted lower linkage to care within three months of diagnosis in a high-risk cohort of transgender women (TW) and men who have sex with men (MSM) in Lima, Peru.
The study included 604 patient records from a cohort previously enrolled in the Sabes study1—a multidimensional HIV study conducted in Lima—where patients were surveyed for HIV stigma awareness and coping strategies before diagnosis, tested for HIV, and followed for receipt of linkage to care. Individuals who had tested positive for HIV during the Sabes study, had been assigned male at birth (cis men or trans women), reported sex with a male within the previous year, and were at high risk of HIV infection due to inconsistent condom use, multiple partners, STD history, or self-identification as a sex worker were eligible for analysis in the current study. The Sabes study had previously performed an initial screening on participants to assess their awareness and perception related to HIV stigma and to gauge their personal dispositional coping skills. Demographic and behavioral factors that may influence a person’s ability or willingness to seek HIV-related care were also evaluated. Dispositional coping behaviors were assigned as adaptive or maladaptive based on scaled answers to questions regarding stressors using published guidelines2. Behaviors such as self-distraction, emotional support, acceptance, spirituality, and humor were among those scored as adaptive while behaviors such as denial and substance use were weighted as maladaptive and perception of HIV stigma was assessed by responses to a standardized HIV-related stigma appraisal3. Finally, the authors cross checked the Sabes study records with the Peruvian National HIV treatment database to determine if patients attended an HIV care visit within three months of diagnoses.
Using data from the Sabes study, the authors applied multivariate analyses to determine the association between psychosocial factors pre-diagnosis to timely receipt of care post-diagnosis. Most strikingly, individuals with dispositional maladaptive coping were significantly less likely to link to care within three months. Additionally, adaptive dispositional coping was also non-significantly related to higher linkage to care. These results demonstrate that psychosocial factors can both individually and multiplicatively affect healthcare outcomes regarding HIV. Awareness of HIV stigma before diagnosis was not found to be significantly related to HIV care linkage after HIV diagnosis. However, the authors note that several features of this study may have obscured a relationship that could in fact exist. For example, participants were asked about HIV stigma while their own HIV status was still unknown, which may evoke different responses than would questions about HIV stigma posed to someone with a known HIV-positive status. Additionally, the literature suggests that perceptions of HIV stigma pre-diagnosis are not correlated with perceptions of stigma post-diagnosis, which may also hold for this study.
This research began to elucidate the consequences of pre-diagnosis psychosocial factors on HIV care, interrogating a novel focus of HIV research, as “HIV stigma and dispositional coping data prior to return of HIV results at screening” are typically not collected, Duerr and her colleagues highlight. Further research is needed to interrogate how pre-diagnosis factors relating to behavior, attitude, and coping influence the post-diagnosis well-being and interaction with medical and social HIV-related care. Together, the results of the current study will contribute to understanding the multifaceted psychosocial factors that govern high-risk communities’ responses to HIV diagnoses, leading to the development of evidence-based interventions. Additionally, Duerr’s group conducts other HIV-related research with data collected from the Sabes study. The Duerr group, which collaborated with Dr. Molina for the above publication, focuses on HIV prevention and the biological features of HIV infection (including factors linked to HIV-associated activation and HIV reservoir). The Sabes study tested participants for HIV RNA and antibodies, allowing the identification of people who had become infected within the previous month. These recently infected individuals were enrolled into a long-term follow-up study in which clinical parameters such as viral load, CD4+ T cell counts, inflammatory markers as well as data on the HIV reservoir, microbiome, and HIV integration sites are also being collected. These ongoing studies will provide insight into “the course of HIV infection and the factors that influence it,” Duerr says. Together, the Sabes study provides a framework to study social, virological, and biological factors of HIV infection which will help guide future prevention and treatment from multiple angles.
2Carver 1997; Perczek, Carver, Price, & Pozo-Kaderman 2000
3Molina & Ramirez-Valles 2013; Ramirez-Valles, Molina, and Dirkes 2013
Molina Y, Ulrich A, Greer AC, Primbas A, Wandell G, Sanchez H, Bain C, Konda KA, Clark JL, De la Grecca R, Villarán MV, Pasalar S, Lama JR, Duerr AC. 2019. Impact of pre-diagnosis awareness of HIV-related stigma and dispositional coping on linkage to HIV care among newly diagnosed HIV+ Peruvian patients. AIDS Care. Jan 7:1-9. doi: 10.1080/09540121.2018.1563282.
This work was funded by the National Institute on Drug Abuse (Duerr), the National Cancer Institute (Molina), and the University of Washington Center for AIDS Research International Pilot Award, supported by the National Institutes of Health (De la Grecca).
Cancer Consortium member Ann Duerr (Fred Hutch) contributed to this work.