Intersectionality of internalized HIV stigma and internalized substance use stigma: Implications for depressive symptoms

Introduction

A substantial body of evidence demonstrates that people living with HIV (PLWH) who have internalized HIV stigma are more likely to be depressed and experience depressive symptoms (Lee et al., 2002; Mak et al., 2007; Riggs et al., 2007; Simbayi et al., 2007). Internalized stigma involves endorsing negative feelings and beliefs associated with a socially devalued characteristic such as HIV and applying them to the self (Link, 1987). For example, PLWH who have internalized HIV stigma may feel “less than” others, and/or dirty or unclean because of their HIV status. In addition to internalizing stigma associated with HIV, PLWH may internalize stigma associated with other socially devalued characteristics such as a history of substance use; lesbian, gay, or bisexual orientation; minority race and/or ethnicity; sex work; and/or incarceration. In this study, we examine whether the relationship between internalized HIV stigma and depressive symptoms is moderated, or changed, by internalized substance use stigma. Findings may provide a stronger understanding of how internalized stigma relates to depressive symptoms among PLWH living with multiple socially devalued characteristics.

Recent theoretical work emphasizes the importance of adopting an intersectionality framework to best conceptualize how living with multiple socially devalued characteristics impacts the health of PLWH (Earnshaw et al., 2013a; Logie et al., 2011). An intersectionality framework suggests that socially devalued characteristics are often interdependent and may interact with each other to influence outcomes (Berger, 2004; Cole, 2009). Empirical work increasingly supports this perspective. Within a qualitative study, women living with HIV stressed the importance of attending to the effects of stigma associated with HIV, sex work, race, sexual orientation, and gender identity simultaneously (Logie et al., 2011). Results of quantitative studies demonstrate that analyses that examine enacted stigma (i.e. experiences of discrimination from others) associated with multiple socially devalued characteristics are better able to explain the impact of stigma on outcomes such as depression (Logie et al., 2013) and antiretroviral adherence (Bogart et al., 2010) than analyses that examine enacted stigma associated with just one characteristic. No known studies, however, have examined whether internalized HIV stigma interacts or intersects with internalized stigma associated with other socially devalued characteristics to impact depressive symptoms among PLWH.

We focus on internalized substance use stigma in the current investigation partly because many PLWH in the United States have a history of substance use. Approximately 7% of new HIV diagnoses and 12% of AIDS diagnoses in 2011 were among people who had engaged in injection drug use (Centers for Disease Control and Prevention, 2013). Many other PLWH have used noninjection substances such as crack cocaine (Edlin et al., 1994), methamphetamine (Patterson et al., 2005), and alcohol (Galvan et al., 2002). Additionally, people with a history of substance use report high levels of internalized substance use stigma (Luoma et al., 2007). Similar to internalized HIV stigma, internalized substance use stigma is associated with poor outcomes including worse mental health and less engagement in substance abuse treatment services (Luoma et al., 2007).

In this study, we aimed to explore intersectionality between internalized HIV stigma and internalized substance use stigma by examining whether the effect of internalized HIV stigma on depressive symptoms is moderated by internalized substance use stigma. We hypothesized that internalized substance use stigma worsens the impact of internalized HIV stigma on depressive symptoms among PLWH with a history of substance use.

Methods

Results

The regression analysis demonstrated a statistically significant interaction between internalized HIV stigma and internalized substance use stigma on depressive symptoms (B (standard error; SE) = 0.63 (0.22)), t = 2.86, p < .01). As shown in Figure 1, at low to moderate percentiles (i.e. 10th–75th) of substance use stigma, the association between internalized HIV stigma and depressive symptoms is not statistically significant. At the highest percentile (i.e. 90th) of substance use stigma, in contrast, the association between internalized HIV stigma and depressive symptoms is statistically significant (B (SE) = 0.73 (0.32), t = 2.25, p = .03). Namely, there is a positive association between internalized HIV stigma and depressive symptoms only among participants at the highest percentile of internalized substance use stigma.

OPEN IN VIEWER

Figure 1.

Line graph representing interaction between internalized HIV stigma and internalized substance use stigma on depressive symptoms.

Discussion

Results of this study contribute to a stronger understanding of the association between internalized stigma and depressive symptoms among PLWH with a history of substance use. Internalized substance use stigma moderated the association between internalized HIV stigma and depressive symptoms: Participants who internalized HIV stigma experienced greater depressive symptoms only if they had also internalized substance use stigma. Results suggest that the combination of internalized HIV stigma and internalized substance use stigma may be particularly damaging to the mental health of PLWH.

There are several limitations of this study that future work may expand on. The study was cross-sectional, limiting our ability to form conclusions about whether internalized stigma predicts subsequent depressive symptoms. Future work might employ longitudinal methodology to examine whether internalized stigma predicts depressive symptoms over time. Furthermore, our sample size was small and limited to PLWH with a history of substance use attending a community clinic in the Bronx, New York. Future work should examine whether these results replicate among larger, more diverse samples to test the generalizability of these effects. Relatedly, our sample comprised participants reporting a wide range of substance use, extending from illicit drug use to alcohol use. This allowed us to capture a wide range of internalized substance use stigma. Future work, however, may choose to focus more exclusively on samples with histories of illicit drug use among whom internalized substance use stigma may be stronger. Many of the participants of this study lived with multiple socially devalued characteristics such as minority sexual orientation and/or race/ethnicity. However, we only examined the effects of internalized stigma associated with HIV and substance use. Future work might also examine the effects of internalized stigma associated with lesbian, gay, or bisexual orientation; race/ethnicity; sex work; incarceration; gender; socioeconomic status; and other socially devalued characteristics prevalent in HIV-positive populations.

This work further highlights several other avenues of future research. Results suggest that people who internalize stigma associated with both HIV and substance use are particularly at risk of experiencing depressive symptoms. Future research may focus on this group of people to examine whether they differ from people who do not internalize stigma or people who only internalize stigma associated with one characteristic. People who internalize stigma associated with both characteristics may, for example, also experience high levels of shame in general. Additionally, results suggest that studying stigma associated with multiple characteristics may provide a fuller understanding of the extent to which stigma impacts health outcomes among PLWH. Future research should seek to adopt an intersectionality framework by examining stigma associated with multiple socially devalued characteristics to best understand how stigma impacts health outcomes among PLWH. It is important that researchers continue developing measures of stigma associated with multiple socially devalued characteristics as well as stigma intersectionality to achieve this goal within quantitative work. Finally, although this study focused on intersectionality associated with internalized stigma given evidence of its strong associations with depressive symptoms (Lee et al., 2002; Mak et al., 2007; Simbayi et al., 2007), future research may also examine other stigma mechanisms such as enacted stigma (i.e. experiences of discrimination in the past) and anticipated stigma (i.e. expectations of discrimination in the future). Different stigma mechanisms are associated with different health outcomes among PLWH (Earnshaw et al., 2013c), and therefore, such research may provide a greater breadth of understanding of the impact of stigma on the health of PLWH.

This study has significant implications for clinical practice with PLWH. Healthcare providers might address internalized stigma associated with both HIV and other characteristics among patients living with HIV when intervening to reduce depressive symptoms. Acceptance and Commitment Therapy represents a promising intervention to reduce internalized stigma among people with a history of substance use that may be adapted for PLWH (Luoma et al., 2008). This therapy incorporates aspects of psychological acceptance, cognitive diffusion, mindfulness, value exploration, and human connection. Participants of a pilot study who completed at least 4 hours of Acceptance and Commitment Therapy demonstrated decreased internalized stigma and internalized shame (Luoma et al., 2008). Interventions that incorporate spiritual striving, disengagement coping, acceptance coping, and social sharing of emotion may also be successful in reducing internalized stigma (Cantisano et al., 2012; Gonzalez et al., 2009; Hansen et al., 2013; Perez et al., 2009). Beyond intervening among PLWH to reduce internalized stigma, it is critical to develop strategies to eliminate stigma at the societal level (Campbell et al., 2007). Only by eradicating societal stigma will we prevent individuals from internalizing stigma and ensure that stigma ceases to pose a threat to the health of PLWH.