Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA.
RAND Corporation, Santa Monica, CA, USA.
J Int AIDS Soc. 2018 Oct;21(10):e25198. doi: 10.1002/jia2.25198.
INTRODUCTION: Cross-sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV-1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations. METHODS: Longitudinal data were collected from 398 South African PLWH recruited from testing centres in 2014 to 2015. Self-report data, including internalized stigma and avoidant coping (denying and distracting oneself from stressors), were collected one week and three months following HIV diagnosis. ART initiation at six months and HIV-1 RNA at nine months were extracted from the South Africa National Health Laboratory Service database. Two path analyses were estimated, one testing associations between internalized stigma, avoidant coping and ART initiation, and the other testing associations between internalized stigma, avoidant coping and HIV-1 RNA suppression. RESULTS: Participants were 36 years old, on average, and 63% identified as female, 18% as Zulu and 65% as Xhosa. The two path models fit the data well (ART initiation outcome: X (7) = 8.14, p = 0.32; root mean square error of approximation (RMSEA) = 0.02; comparative fit index (CFI) = 0.92; HIV-1 RNA suppression outcome: X (7) = 6.58, p = 0.47; RMSEA = 0.00; CFI = 1.00). In both models, internalized stigma one week after diagnosis was associated with avoidant coping at three months, controlling for avoidant coping at one week. In turn, avoidant coping at three months was associated with lower likelihood of ART initiation at six months in the first model and lower likelihood of HIV-1 RNA suppression at nine months in the second model. Significant indirect effects were observed between internalized stigma with ART non-initiation and unsuppressed HIV-1 RNA via the mediator of avoidant coping. CONCLUSIONS: Internalized stigma experienced soon after HIV diagnosis predicted lower likelihood of ART initiation and HIV-1 RNA suppression over the first year following HIV diagnosis. Avoidant coping played a role in these associations, suggesting that PLWH who internalize stigma engage in greater avoidant coping, which in turn worsens medication- and health-related outcomes. Interventions are needed to address internalized stigma and avoidant coping soon after HIV diagnosis to enhance treatment efforts during the first year after HIV diagnosis.
简介：横断面研究表明，HIV 感染者内化的耻辱感与抗逆转录病毒治疗（ART）的启动率较低以及 HIV-1 病毒载量抑制率较低有关。本研究使用纵向数据（随访时间跨越 HIV 诊断后的头 9 个月）来检验这些关联，并探讨回避应对是否在这些关联中起中介作用。
方法：2014 年至 2015 年，从南非的检测中心招募了 398 名 HIV 感染者，收集了他们的纵向数据。在 HIV 诊断后一周和三个月时，通过自我报告的方式收集了内化耻辱感和回避应对（否认和分散压力源）的数据。从南非国家卫生实验室服务数据库中提取了六个月时的 ART 启动情况和九个月时的 HIV-1 病毒载量。估计了两个路径分析模型，一个检验了内化耻辱感、回避应对与 ART 启动之间的关联，另一个检验了内化耻辱感、回避应对与 HIV-1 病毒载量抑制之间的关联。
结果：参与者的平均年龄为 36 岁，63%为女性，18%为祖鲁族，65%为科萨族。两个路径模型都很好地拟合了数据（ART 启动结果：X (7) = 8.14，p = 0.32；近似均方根误差（RMSEA）= 0.02；比较拟合指数（CFI）= 0.92；HIV-1 病毒载量抑制结果：X (7) = 6.58，p = 0.47；RMSEA = 0.00；CFI = 1.00）。在两个模型中，诊断后一周的内化耻辱感与三个月时的回避应对相关，控制了一周时的回避应对。反过来，三个月时的回避应对与六个月时 ART 启动率较低有关，在第一个模型中与九个月时 HIV-1 病毒载量抑制率较低有关，在第二个模型中与九个月时 HIV-1 病毒载量抑制率较低有关。通过回避应对这一中介，在内化耻辱感与 ART 不启动和未抑制的 HIV-1 RNA 之间观察到了显著的间接效应。
结论：HIV 诊断后不久出现的内化耻辱感预测了 HIV 诊断后第一年 ART 启动和 HIV-1 病毒载量抑制率较低。回避应对在这些关联中起作用，这表明内化耻辱感的 HIV 感染者会采用更多的回避应对，从而导致药物治疗和健康相关结果恶化。需要在 HIV 诊断后不久采取干预措施来解决内化耻辱感和回避应对问题，以增强 HIV 诊断后第一年的治疗效果。
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