Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis.

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

'Yeah, they suck. It's like they don't care about our health.' Medical mistrust among Black women under community supervision in New York city.

Black women in the USA experience some of the poorest health outcomes and this is especially true for those involved in the carceral system who are at elevated risks for HIV/STIs, reproductive health, and chronic diseases. This study aimed to investigate Black women's experience accessing healthcare services. We conducted semi-structured interviews with 43 women from Project EWORTH under community supervision in New York City. We analysed responses focusing on barriers to healthcare engagement. All interviews were recorded, and data analysis was conducted using NVivo. Themes influencing Black women's ability to engage with healthcare providers and systems included: 1) disclosed provider mistrust/judgement; 2) feeling disrespected by providers and the medical system; 3) mistrust of medical providers/system/hospital/government; 4) lack of health communication; 5) low health literacy; 6) provider gender preference. Findings highlight the need to improve trust and collaboration between healthcare providers and Black women. This study addresses the critical gap in understanding perceptions of discrimination, stigma, and barriers to attaining health care. Funders and accreditation agencies must hold providers and organisations accountable for acquiring and making available diversity, equity and inclusion training for providers, demonstrating increasingly equitable medical relationships through responsiveness to patient feedback, and increasing the number of Black providers.

Assessing the relationship between syringe exchange, pharmacy, and street sources of accessing syringes and injection drug use behavior in a pooled nationally representative sample of people who inject drugs in the United States from 2002 to 2019.

Provision of sterile syringes is an evidence-based strategy of reducing syringe sharing and reusing and yet, access to sterile syringes through pharmacies and syringe exchange programs (SEPs) in the United States remains inadequate. This nationally representative study examined associations between obtaining syringes from pharmacies, SEPs, and sterilizing syringes with bleach and risk of syringe borrowing, lending and reusing syringes in a pooled cross-sectional dataset of 1737 PWID from the 2002-2019 National Survey on Drug Use and Health. Logistic regression was used to produce odds ratios (OR) of the odds of injection drug behaviors after adjusting for obtaining syringes from SEPs, pharmacies, the street, and other sources and potential confounders of race, ethnicity, sex, education, and insurance coverage. Obtaining syringes through SEPs was associated with lower odds of borrowing (OR = .4, CI95% = .2, .9, p = .022) and reusing syringes (OR = .3, CI95% = .2, .6, < .001) compared to obtaining syringes on the street. Obtaining syringes from pharmacies was associated with lower odds of borrowing (OR = .5, CI95% = .3, .9, p = .037) and lending (OR = .5 CI95% = .3, .9, p = .020) syringes. Using bleach to clean syringes was associated with increased odds of borrowing (OR = 2.0, CI95% = 1.3, 3.0, p = .002), lending (OR = 2.0, CI95% = 1.3, 3.0, p = .002) and reusing syringes (OR = 2.4, CI95% = 1.6, 3.6, p < .001). Our findings support provision of syringes through pharmacies and SEPs as a gold-standard strategy of reducing sharing and reuse of syringes in the US.

Stigma and US Nurses' Intentions to Provide the Standard of Maternal Care to Incarcerated Women, 2017.

Objectives. To examine relationships among actionable drivers and facilitators of stigma and nurses' intentions to provide the standard of maternal care recommended by the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) for incarcerated women.Methods. We conducted a Web-based survey of perinatal nurses in the United States (n = 665; participation rate 98.0%; completion rate 95.3%) in July through September 2017. We used multivariable logistic regression to predict higher than median intentions to provide the standard of care.Results. Lower stigmatizing individual attitudes and institutional norms and higher perceived autonomy when caring for an incarcerated woman were significantly associated with higher care intentions. Knowledge of the AWHONN position statement on the standard of care or their own state's shackling laws was not associated with higher care intentions.Conclusions. We documented significant associations among actionable drivers and facilitators of stigma and the intentions of a key health care provider group to deliver the standard of maternal care to incarcerated women. Individual- and institutional-level stigma-reduction interventions may increase the quality of maternal care and improve perinatal outcomes for women who give birth while incarcerated.

Mental Health Consequences of Sexual Misconduct by Law Enforcement and Criminal Justice Personnel among Black Drug-Involved Women in Community Corrections.

This study examines the prevalence, correlates, and mental health consequences of sexual misconduct by law enforcement and criminal justice (LECJ) personnel. Baseline data for Project E-WORTH (Empowering African-American Women on the Road to Health) were collected between November 2015 and May 2018 from 351 drug-involved Black women from community corrections in New York City. LECJ sexual misconduct was self-reported and we measured mental health outcomes with the CESD-4 and the PTSD Checklist. Univariate and multivariable logistic regression analyses were performed. Approximately 14% of our sample had experienced LECJ sexual misconduct. Participants who reported multiple arrests, recent drug use, and having experienced childhood sexual victimization were more likely to have experienced LECJ sexual misconduct. Further, LECJ sexual misconduct was positively associated with depression and PTSD. These findings suggest that LECJ sexual misconduct is a previously unreported risk factor for adverse mental health outcomes among criminal-legal system-involved women. There is a need for recognition of LECJ sexual victimization among criminal-legal system-involved women. As such, prevention, treatment, and community corrections service delivery for this population should be trauma informed.

Feasibility and Acceptability of Real-Time Antiretroviral Adherence Monitoring among Depressed Women Living with HIV in the Deep South of the US.

This study presents feasibility and acceptability data on the use of a real-time wireless electronic adherence monitor (EAM), among African American women living with HIV with co-occurring depression, residing in remote areas of the Southeastern United States. EAM and self-report ART adherence was monitored over an average of 14.8 weeks among 25 participants who were recruited at four HIV clinics in Alabama. Intra-class correlation showed a low degree of concordance between EAM and self-report (ICC = 0.33, 95% bootstrap CI 0.13, 0.59). 83% of data collected via EAM was transmitted in real-time. Due to technological failures, 11.4% were not transmitted in real-time, but were later recovered, and 5.7% were lost entirely. Acceptability was examined through surveys and qualitative interviews. Results suggest that EAM monitoring is acceptable and feasible in a rural US setting; however, technological difficulties, such as loss of connectivity may impede the device's usefulness for just-in-time adherence interventions.

Accessing Pre-exposure Prophylaxis (PrEP): Perceptions of Current and Potential PrEP Users in Birmingham, Alabama.

Limited studies to date assess barriers to and facilitators of PrEP uptake and utilization using a patient-centered access to care framework, among diverse socio-demographic groups, or in the U.S. Deep South, an area with disproportionate HIV burden. We examine perceptions of PrEP access in qualitative interviews with 44 current and potential PrEP users in Birmingham, Alabama. Participants were 32 years old on average, 66% Black, 66% gay or lesbian, 70% male, and 66% single. Perceived barriers to PrEP access included: lack of PrEP awareness and advertisement; sexuality-related stigma; time and resource constraints; and concerns about the adequacy and technical quality of PrEP services. Perceived facilitators to PrEP access were: PrEP-related information gathering and sharing; increased dialogue and visibility around PrEP; social, programmatic, and clinical support; and, lastly, self-preservation; personal motivation; and treatment self-efficacy. Results point to opportunities to address complex barriers to equitable PrEP access using multilevel and multimodal solutions.

Stigma as a Barrier to Substance Abuse Treatment Among Those With Unmet Need: An Analysis of Parenthood and Marital Status.

Substance use (SU) stigma is one factor contributing to unmet need for SU treatment. Additionally, theory suggests that women and single parents who use substances experience enhanced stigma because they do not adhere to normative social expectations. This study examines differences in perceived stigma by gender and parenthood among those with unmet need for SU treatment using the 2003-2010 National Survey of Drug Use and Health (N = 1,474). Results indicate that women are more likely to report stigma as a barrier to treatment compared with men, though the interaction between gender and parenthood is not significant. We find that married parents report the highest level of stigma. We situate our findings in past health-related stigma research. We suggest that these results shed a light on stigma, particularly as it relates to family status, as a contributing factor to differences regarding SU treatment utilization. Finally, we raise a provocative question concerning social status and anticipated stigma.

HIV-Related Stigma Among Healthcare Providers in the Deep South.

Stigma towards people living with HIV (PLWH) in healthcare settings is a barrier to optimal treatment. However, our understanding of attitudes towards PLWH from healthcare providers' perspective in the United States is limited and out-of-date. We assessed HIV-related stigma among healthcare staff in Alabama and Mississippi, using online questionnaires. Participants included 651 health workers (60 % White race; 83 % female). Multivariate regression suggests that several factors independently predict stigmatizing attitudes: Protestant compared to other religions (ß = 0.129, p ≤ 0.05), White race compared to other races (ß = 0.162, p ≤ 0.001), type of clinic (HIV/STI clinic: ß = 0.112, p ≤ 0.01), availability of post-exposure prophylaxis (yes: ß = -0.107, p ≤ 0.05), and perceptions of policy enforcement (policies not enforced: ß = 0.058, p = p ≤ 0.05). These findings may assist providers wishing to improve the quality care for PLWH. Enforcement of policies prohibiting discrimination may be a useful strategy for reducing HIV-related stigma among healthcare workers.

Linkage to HIV care, postpartum depression, and HIV-related stigma in newly diagnosed pregnant women living with HIV in Kenya: a longitudinal observational study.

BACKGROUND: While studies have suggested that depression and HIV-related stigma may impede access to care, a growing body of literature also suggests that access to HIV care itself may help to decrease internalized HIV-related stigma and symptoms of depression in the general population of persons living with HIV. However, this has not been investigated in postpartum women living with HIV. Furthermore, linkage to care itself may have additional impacts on postpartum depression beyond the effects of antiretroviral therapy. We examined associations between linkage to HIV care, postpartum depression, and internalized stigma in a population with a high risk of depression: newly diagnosed HIV-positive pregnant women. METHODS: In this prospective observational study, data were obtained from 135 HIV-positive women from eight antenatal clinics in the rural Nyanza Province of Kenya at their first antenatal visit (prior to testing HIV-positive for the first time) and subsequently at 6 weeks after giving birth. RESULTS: At 6 weeks postpartum, women who had not linked to HIV care after testing positive at their first antenatal visit had higher levels of depression and internalized stigma, compared to women who had linked to care. Internalized stigma mediated the effect of linkage to care on depression. Furthermore, participants who had both linked to HIV care and initiated antiretroviral therapy reported the lowest levels of depressive symptoms. CONCLUSIONS: These results provide further support for current efforts to ensure that women who are newly diagnosed with HIV during pregnancy become linked to HIV care as early as possible, with important benefits for both physical and mental health.

Community-level determinants of stakeholder perceptions of community stigma toward people with opioid use disorders, harm reduction services and treatment in the HEALing Communities Study.

BACKGROUND: Community stigma toward people with opioid use disorder (OUD) can impede access to harm reduction services and treatment with medications for opioid use disorder (MOUD). Such community OUD stigma is partially rooted in community-level social and economic conditions, yet there remains a paucity of large-scale quantitative data examining community-level factors associated with OUD stigma. We examined whether rurality, social inequity, and racialized segregation across communities from four states in the HEALing Communities Study (HCS) were associated with 1) greater perceived community stigma toward people treated for OUD, 2) greater perceived intervention stigma toward MOUD, and 3) greater perceived intervention stigma toward naloxone by community stakeholders in the HCS. METHODS: From November 2019-January 2020, a cross-sectional survey about community OUD stigma was administered to 801 members of opioid overdose prevention coalitions across 66 communities in four states prior to the start of HCS intervention activities. Bivariate analyses assessed pairwise associations between community rural/urban status and each of the three stigma variables, using linear mixed effect modeling to account for response clustering within communities, state, and respondent sociodemographic characteristics. We conducted similar bivariate analyses to assess pairwise associations between racialized segregation and social inequity. RESULTS: On average, the perceived community OUD stigma scale score of stakeholders from rural communities was 4% higher (ß=1.57, SE=0.7, p≤0.05), stigma toward MOUD was 6% higher (ß=0.28, SE=0.1, p≤0.05), and stigma toward naloxone was 10% higher (ß=0.46, SE=0.1, p≤0.01) than among stakeholders from urban communities. No significant differences in the three stigma variables were found among communities based on racialized segregation or social inequity. CONCLUSION: Perceived community stigma toward people treated for OUD, MOUD, and naloxone was higher among stakeholders in rural communities than in urban communities. Findings suggest that interventions and policies to reduce community-level stigma, particularly in rural areas, are warranted.

Increased spreading activation in depression.

The dopaminergic system is implicated in depressive disorders and research has also shown that dopamine constricts lexical/semantic networks by reducing spreading activation. Hence, depression, which is linked to reductions of dopamine, may be associated with increased spreading activation. However, research has generally found no effects of depression on spreading activation, using semantic priming paradigms. We used a different paradigm to investigate the relationship between depression and spreading activation, one based on word frequencies. Our sample included 97 undergraduates who completed the BDI-II and the Controlled Oral Word Association test as well as the Animal Naming test. The results indicated that the group scoring within the depressed ranged evidenced greater spreading activation as compared to those who scored within the normal range on the BDI-II. The implications of these results as they relate to creativity in depression is discussed.

Leveraging COVID-19 to sustain regulatory flexibility in the treatment of opioid use disorder.

The U.S. government declared the opioid epidemic as a national public health emergency in 2017, but regulatory frameworks that govern the treatment of opioid use disorder (OUD) through pharmaceutical interventions have remained inflexible. The emergence of the COVID-19 pandemic has effectively removed regulatory restrictions that experts in the field of medications for opioid use disorder (MOUD) have been proposing for decades and has expanded access to care. The regulatory flexibilities implemented to avoid unnecessary COVID-related death must be made permanent to ensure that improved access to evidence-based treatment remains available to vulnerable individuals with OUD who otherwise face formidable barriers to MOUD. We must seize this moment of COVOD-19 regulatory flexibilities to demonstrate the feasibility, acceptability, and safety of delivering treatment for OUD through a low-threshold approach.

Socio-ecological and pharmacy-level factors associated with buprenorphine stocking at pharmacies in New York City.

BACKGROUND: Research is lacking on community and pharmacy-level factors that are associated with stocking buprenorphine. To address these gaps, this study applied a socio-ecological framework to estimate the association between community- and pharmacy-level factors and buprenorphine stocking among a sample of pharmacies in New York City. METHODS: A telephone survey recruitment strategy was used to administer surveys to 662 pharmacies on the New York City Naloxone Standing Order Pharmacy list in 2018. The survey assessed pharmacy-level factors of private spaces to consult with pharmacists, type of pharmacy (chain/independent), size of pharmacy, having buprenorphine in stock and being open on nights and weekends. Socio-ecological variables drawn from census tract and public health data consisted of racial and ethnic composition, rates of poverty, rates of people without insurance, and rates of overdose. Mixed effects logistic regression estimated odds ratios (OR) of carrying buprenorphine in stock after adjusting for socio-ecological and pharmacy-level factors. RESULTS: Fewer than half of the pharmacies reported having buprenorphine in stock (43.81% n = 290). Logistic regression analyses indicate that several pharmacy-level factors - the number of private spaces (aOR=1.67 95% CI=1.20, 2.32 p=.002), large size of the pharmacy (aOR=1.52 95% CI=1.04, 2.22, p=.032), having naloxone in stock (aOR=1.54, 95%CI=1.03, 2.32 p=.037), as well as neighborhood-level factors of higher rates of poverty (aOR=2.07 95%CI=1.07, 4.02 p<.001) and higher rates of uninsured residents were associated with carrying buprenorphine (aOR=0.23 95%CI=0.14,.38). CONCLUSIONS: Using a socio-ecological framework, this study identified inequities in pharmacy stocking of buprenorphine by neighborhood rates of health insurance. At the pharmacy level, increasing private spaces for consultation and encouraging co-stocking of naloxone with buprenorphine stocking may reduce inequalities in buprenorphine availability.

Complexities of HIV Disclosure in Patients Newly Entering HIV Care: A Qualitative Analysis.

The role of HIV disclosure and its influence on engagement in HIV care after initial linkage to care is not well understood. We conducted 28 in-depth interviews with patients newly entering HIV care. Gaining access to social support was a key reason that many patients disclosed their HIV status. For some, HIV disclosure improved support networks related to engagement in care at the time of care entry, in the form of appointment reminders, emotional support, and confidence to disclose more widely. However, some participants cited anticipated stigma as a barrier to disclosure, as they feared rejection or further disclosure without their permission. Early access to social support and skill building related to stigma reduction and coping can be useful resources to help patients manage HIV, as they initiate care. In addition, incorporating support for smart disclosure decisions into interventions may improve access to social support, ultimately improving engagement in care.

Assessing factors associated with discharge from opioid agonist therapy due to incarceration in the United States.

The following study investigates factors associated with discharge from OAT due to incarceration in a sample of 64,331 discharges in the United States. Multinomial regression investigated the association between demographic factors, prior arrest, referral source (i.e criminal justice agency) intravenous drug use, types of drug used, length of prior treatment and discharge due to incarceration compared to completing treatment or discharge due to other reasons. African Americans, Latinx, and Native Americans were at greater risk of discharge due to incarceration compared to whites. Referral to OAT from criminal justice agencies and self-referral was associated with increased risk of discharge from OAT due to incarceration compared to referral from a health care provider. Substance use of heroin, benzodiazepines, synthetic opioids, cocaine and non-prescription use of methadone were associated with discharge due to incarceration. Risk of discharge due to incarceration was higher for patients who reported intravenous drug use and who reported a co-morbid psychiatric problem. These findings enrich a nascent body of literature on mechanisms associated with attrition from OAT due to incarceration and emphasize the need for programs to divert people with OUD from incarceration to increase engagement and retention in OAT.

Substance Use Stigma and Antiretroviral Therapy Adherence Among a Drug-Using Population Living with HIV.

Among people living with HIV (PLWH), HIV-related stigma predicts nonadherence to antiretroviral therapy (ART); however, the role of stigma associated with drug use is largely unknown. We examined the association between substance use (SU) stigma and optimal ART adherence in a sample of 172 self-reported HIV-infected drug users. Participants completed surveys on SU, stigma, and ART adherence. The three substance classes with the greatest number of participants exhibiting moderate/high-risk scores were for cocaine/crack cocaine (66.28%), cannabis (64.53%), and hazardous alcohol consumption (65.70%). Multivariable logistic regression was conducted to investigate associations between levels of SU stigma and optimal ART adherence, adjusting for sociodemographic characteristics, severity of illicit drug use (alcohol, smoking and substance involvement screening test) and alcohol use severity (Alcohol Use Disorders Identification Test-C), HIV-related stigma, and social support. The odds of optimal adherence among participants experiencing moderate [Adjusted Odds Ratio (AOR) = 0.36, p = 0.039] and very high (AOR = 0.25, p = 0.010) levels of anticipated SU stigma were significantly lower than participants experiencing low levels of anticipated SU stigma. No other stigma subscales were significant predictors of ART adherence. Interventions aiming to improve ART adherence among drug-using PLWH need to address anticipated SU stigma.

Attitudes towards people living with HIV and people who inject drugs: A mixed method study of stigmas within harm reduction programs in Kazakhstan.

BACKGROUND: High levels of stigma towards people who inject drugs (PWID) and people living with HIV (PLWH) exist in Kazakhstan, yet little is known about the role of stigma in harm reduction service settings. In this paper, we use a mixed method design to explore and describe the actionable drivers and facilitators of stigma among harm reduction service providers. Additionally, we describe the manifestations of stigma among PWID who are living with HIV (PWID/LWH), and the impact that stigma has on harm reduction and healthcare service utilization. METHODS: Eight focus groups with 57 PWID/LWH were convened between March 2016 and July 2016 to describe manifestations of stigma from the perspective of syringe exchange program (SEP) clients. Additionally, we surveyed 80 nurses, social workers, outreach workers, and providers of HIV care at SEPs between January 2017 and July 2017 to assess stigmatizing attitudes among staff within the SEP environment. Joint displays were used to integrate quantitative and qualitative data. RESULTS: The actionable drivers of stigma identified in this study include negative opinions and moral judgements towards PWID/LWH. Facilitators identified included stigmatization as a social norm within the service provision environment, a lack of awareness of anti-discrimination policies, and lack of enforcement of anti-discrimination policies. Qualitative findings highlight manifestations of stigma in which PWID/LWH experienced denial of services, perceived negative attitudes, and avoidance from service provision staff. PWID/LWH also described segregation in healthcare settings, the use of unnecessary precautions by providers, and unauthorized disclosure of HIV status. CONCLUSIONS: This paper highlights the urgent need to address stigma in the harm reduction and HIV service settings in Kazakhstan. These findings have implications for informing an actionable model for stigma reduction for providers who deliver services to PWID/LWH in Kazakhstan. Drivers, facilitators, and manifestations of stigma are multifaceted and addressing them will require a multilevel approach.