What shapes resilience among people living with HIV? A multi-country analysis of data from the PLHIV Stigma Index 2.0.

OBJECTIVE: To inform efforts to promote greater resilience among people living with HIV (PLHIV), we examined associations between resilience and factors at the individual, interpersonal and structural/policy levels in three countries. DESIGN: Data come from the PLHIV Stigma Index 2.0, a cross-sectional survey with PLHIV, implemented from 2017 to 2019 in Cambodia (n = 1207), the Dominican Republic (n = 891), and Uganda (n = 391). METHODS: Hierarchical multiple regression was used to assess associations between resilience and factors at the individual/interpersonal/structural-policy levels, controlling for potential confounders. Resilience was measured by the previously tested PLHIV Resilience Scale. RESULTS: About 60% of respondents were women; mean time since HIV diagnosis was 11 years in Cambodia and seven in the Dominican Republic /Uganda. Resilience varied substantially across the six province/districts per country (all p < 0.001). In multivariable analyses, higher resilience was associated with lower internalized stigma (all three countries), no experience of human rights abuses (Dominican Republic), no food/housing insecurity (Uganda), and greater community awareness of legal protections for PLHIV (Cambodia and Dominican Republic). HIV-related enacted stigma (i.e., discrimination) in the community was associated with lower resilience in Cambodia, but higher resilience in the Dominican Republic. The set of structural/policy-level factors in Cambodia and the Dominican Republic, and individual-level in Uganda, explained the most variance in resilience. CONCLUSION: Factors at multiple levels affect whether PLHIV in Cambodia, the Dominican Republic, and Uganda report resilience. Multilevel interventions are required to promote resilience among PLHIV, and should incorporate efforts to reduce internalized stigma and promote supportive structural/legal environments including broader awareness of legal protections for PLHIV.

Internalized stigma among people living with HIV: assessing the Internalized AIDS-Related Stigma Scale in four countries.

OBJECTIVE: Measuring internalized stigma is critical to understanding its impact on the health and quality of life of people living with HIV (PLHIV). The aim of this study was to assess the performance of the Internalized AIDS-Related Stigma Scale (IA-RSS). DESIGN: Secondary analysis of the six-item IA-RSS was conducted using data from four cross-sectional surveys implemented in Cambodia (n = 1207), the Dominican Republic (n = 891), Uganda (n = 391) and Tanzania (n = 529) between 2018 and 2019. METHODS: IA-RSS scale item distribution was described. Multivariate regression models measured correlations between the IA-RSS and depression, antiretroviral therapy (ART) use and viral suppression. Confirmatory factor analysis assessed IA-RSS reliability and performance through analysis of standardized factor loadings and conditional probabilities of scale items. Analysis of qualitative interviews with PLHIV explored acceptability of IA-RSS item content. RESULTS: Mean IA-RSS scores (possible 0-6) ranged from 2.06 (Uganda) to 3.84 (Cambodia), and internal consistency was more than 0.70 in each country (Kuder-Richardson 20), ranging from 0.71 to 0.83. Higher IA-RSS scores were strongly correlated with depression in (P < 0.001 in all countries), and inversely associated with current ART use (Dominican Republic and Tanzania) and self-reported viral suppression (Uganda and Tanzania). Confirmatory factor analysis showed good model fit (all CFI ≥ 0.950), but also that the IA-RSS may summarize two domains related to HIV status disclosure (two items) and PLHIV feelings about themselves (four items). CONCLUSION: Strong performance across countries supports continued use of the IA-RSS. Further study is needed to explore potential item refinements and to better understand the relationship between internalized stigma and HIV treatment outcomes.