Abstract
The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized. Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial. We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding. Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression. Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.
Highlights
Increasing the proportion of people living with HIV (PLHIV) who are virally suppressed is critical.[1]
Of all 5662 PLHIV, 69.1% were virally suppressed at population cohort 24 months after enrolment (PC24)
Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on antiretroviral treatment (ART) (88.3%), and lower among those not on treatment (37.5%)
Summary
Increasing the proportion of people living with HIV (PLHIV) who are virally suppressed is critical.[1]. Stigma acts as a barrier to PLHIV accessing care in the United States,[7] among pregnant women who test positive in antenatal settings in Africa,[8] and more generally in low- and middle-income settings.[9] Adherence to antiretroviral medication is lower in the presence of stigma among young people in the United States[10] and globally[11] because stigma negatively affects mental health and prevents PLHIV from disclosing their status to others and accessing psychosocial support.[6] We investigated the association between HIV stigma and viral suppression among a large, representative sample of PLHIV in the 21 communities participating in the HPTN 071 (PopART) trial in Zambia and South Africa.[12,13] At 24 months (PC24), we assessed (1) whether PLHIV who reported experienced, internalized, or perceived stigma had lower rates of viral suppression, (2) whether PLHIV living in communities with higher levels of stigma had lower rates of viral suppression among PLHIV, and, (3) whether associations differed between the arms of the trial, which delivered different approaches to HIV testing and treatment. The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized.
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