Hoffman Susie, Tymejczyk Olga, Kulkarni Sarah, Lahuerta Maria, Gadisa Tsigereda, Remien Robert H, Melaku Zenebe, Nash Denis, Elul Batya
*HIV Center for Clinical and Behavioral Studies at the NYS Psychiatric Institute and Columbia University, New York City, NY; †Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, NY; ‡Graduate School of Public Health and Health Policy, City University of New York, New York, NY; §Institute of Implementation Science in Population Health, City University of New York, New York, NY; and ‖ICAP, Columbia University Mailman School of Public Health, New York City, NY.
J Acquir Immune Defic Syndr. 2017 Dec 1;76(4):382-387. doi: 10.1097/QAI.0000000000001530.
Stigma harms the mental health of HIV-positive individuals and reduces adherence to antiretroviral therapy (ART), but less is known about stigma and other outcomes across the HIV care continuum.
Among 1180 Ethiopian adults initiating ART at 6 urban HIV clinics, we examined the relationship of internalized, anticipated, and enacted stigma to HIV care-related outcomes ascertained by interview (repeat HIV-positive testing, provider vs. self-referred testing, missed clinic visit before ART initiation, eagerness to begin ART), and by abstraction of routinely collected clinical data (late ART initiation, 3-month gap in care following ART initiation). Logistic regression was used to assess the association of each type of stigma with each outcome, adjusting for potential confounders.
Scoring higher on each stigma domain was associated with 50%-90% higher odds of repeat HIV-positive testing. High internalized stigma was associated with higher odds of provider vs. self-referred test [adjusted odds ratio (aOR)high vs. low: 1.7; 95% confidence interval (CI): 1.3 to 2.2]. Higher anticipated stigma was associated with lower eagerness to begin ART (aORhigh vs. low: 0.55; 0.35-0.87; aORmedium vs. low: 0.45; 95% CI: 0.30 to 0.69). Any enacted stigma was associated with higher odds of a missed visit (aORany vs. none 1.8; 1.2-2.8). Stigma was not associated with late ART-initiation or with a subsequent gap in care.
These findings provide further evidence of the importance of measuring and addressing stigma across the entire care continuum. Future work should test hypotheses about specific stigma domains and outcomes in prospective intervention or observational studies.
耻辱感会损害艾滋病毒呈阳性者的心理健康，并降低其对抗逆转录病毒疗法（ART）的依从性，但对于整个艾滋病毒护理连续过程中的耻辱感及其他结果，人们了解较少。
在6家城市艾滋病毒诊所开始接受抗逆转录病毒治疗的1180名埃塞俄比亚成年人中，我们研究了内化耻辱感、预期耻辱感和表现出的耻辱感与通过访谈确定的艾滋病毒护理相关结果（重复艾滋病毒阳性检测、由医护人员推荐与自我推荐检测、在开始抗逆转录病毒治疗前错过诊所就诊、渴望开始抗逆转录病毒治疗）以及通过提取常规收集的临床数据（延迟开始抗逆转录病毒治疗、开始抗逆转录病毒治疗后3个月的护理中断）之间的关系。采用逻辑回归评估每种耻辱感类型与每种结果之间的关联，并对潜在混杂因素进行调整。
在每个耻辱感领域得分较高与重复艾滋病毒阳性检测的几率高50%-90%相关。高度内化的耻辱感与由医护人员推荐检测而非自我推荐检测的几率较高相关[高内化耻辱感与低内化耻辱感的调整比值比（aOR）：1.7；95%置信区间（CI）：1.3至2.2]。较高的预期耻辱感与开始抗逆转录病毒治疗的渴望较低相关（高预期耻辱感与低预期耻辱感的aOR：0.55；0.35 - 0.87；中等预期耻辱感与低预期耻辱感的aOR：0.45；95% CI：0.30至0.69）。任何表现出的耻辱感与错过就诊的几率较高相关（有表现出的耻辱感与无耻辱感的aOR：1.8；1.2 - 2.8）。耻辱感与延迟开始抗逆转录病毒治疗或随后的护理中断无关。
这些发现进一步证明了在整个护理连续过程中测量和解决耻辱感的重要性。未来的工作应在前瞻性干预或观察性研究中检验关于特定耻辱感领域和结果的假设。
