Internalized Stigma in a Population-Based Sample of U.S. HIV-Infected Adults in Care
Amy R. Baugher, MPH1; Linda Beer, PhD1; Jennifer L. Fagan, MA1; Christine L. Mattson, PhD1; Mark Freedman, DVM MPH1; and Jacek Skarbinski, MD1 for the Medical Monitoring Project
1 Centers for Disease Control and Prevention
BACKGROUND

HIV-related internalized stigma is when HIVinfected persons hold negative beliefs about HIV as
true about themselves
Mean
(95% CL)

Stigma is related to poor HIV antiretroviral
treatment (ART) adherence, non-disclosure of HIV
status to sex partners, and depression
Reducing HIV-related stigma is part of the
National HIV/AIDS Strategy

National estimates of stigma among HIV-infected
persons are needed
p-value
Female
Male
Transgender
2.9 (2.8-3.1)
2.4 (2.3-2.6)
3.2 (2.6-3.8)
<0.0001
ref
0.0084
Race/ethnicity
Black, non-Hispanic
2.7 (2.6-2.8)
0.01

Relationship between internalized stigma and
durable viral suppression has not been assessed
Stigma Question
2.6 (2.5-2.6)
Total sample
Gender

Hispanic/Latino
2.7 (2.6-2.9)
0.0002
White, non-Hispanic
2.3 (2.1-2.6)
ref
Other
2.8 (2.5-3.1)
0.03
Age (years)
Objectives: To assess the prevalence of stigma among
HIV-infected persons in the U.S. and the association
between stigma and durable viral suppression
METHODOLOGY

18-24
25-34
2.8 (2.4-3.1)
2.9 (2.6-3.2)
0.0044
<0.0001
35-44
2.8 (2.6-2.9)
<0.0001
45-54
≥55
2.5 (2.4-2.6)
2.3 (2.1-2.5)
0.01
ref
Sexual identity
Heterosexual or straight
The Medical Monitoring Project (MMP) is an
annual cross-sectional survey of a nationally
representative sample of HIV-infected adults receiving
HIV care in the U.S. and Puerto Rico
• Facility response rate : 83%
• Adjusted interview response rate: 52.1%

Table 2. Distribution of Responses to HIV-related Stigma Questions, MMP 2011
Table 1. Comparison of Mean Stigma Scores by
Characteristics, MMP 2011 (n=4,385)
Bisexual
Homosexual, gay, or lesbian
Other
Time since diagnosis date
<5 years
≥5 years
Data collected: May 2011 - April 2012
• Interviews and medical records
Agree (%)
Neutral (%)
Disagree (%)
64.0
6.2
28.8
56.1
35.0
32.8
25.1
23.3
8.8
6.1
6.1
6.4
5.5
34.3
57.9
60.1
67.6
70.2
It is difficult to tell people about my HIV
infection
I hide my HIV status from others
I feel guilty that I am HIV positive
I am ashamed that I am HIV positive
Being HIV positive makes me feel dirty
I sometimes feel worthless because I am HIV
positive
Percentages do not sum to 100% due to rounding. Don’t know answers not included.
Table 3. Bivariate Associations Between Mean Stigma Scores and Behavioral &
Clinical Outcomes, MMP 2011
Outcomes (comparison v. referent)
Mean (95%CL)
Referent Mean
(95% CL)
Major/other depression v. None
3.3* (3.2-3.5)
2.4 (2.3-2.5)
Binge drinking in past 30 days v. None
2.8*(2.6-3.0)
2.6 (2.4-2.7)
Any drug use in past 12 months v. None
2.6 (2.5-2.8)
2.6 (2.5-2.7)
Did not disclose HIV status to all sex partners v.
Disclosed to all
3.2* (3.0-3.3)
2.4 (2.2-2.5)
2.8 (2.7-3.0)
<0.0001
2.7 (2.5-2.9)
2.3 (2.1-2.4)
2.4 (1.8-2.9)
0.0009
ref
0.72
Sex without condom in past 12 months
v. Did not have sex without a condom
2.5 (2.4-2.6)
2.6 (2.5-2.7)
Not 100% adherent to HIV medicines
v. 100% adherent
2.9* (2.8-3.1)
2.5 (2.4-2.6)
3.0 (2.8-3.1)
2.5 (2.4,2.6)
<0.0001
ref
≥1 viral load test detectable /unknown in past 12
months v. All undetectable in past 12 months
2.7** (2.6, 2.8)
2.5 (2.5, 2.6)
*p<0.01; **p<0.05

Figure 1. Comparison of Mean Stigma Scores by ART Use and
Adherence
6

5
Durable viral suppression defined as all viral load
tests in past 12 months documented as undetectable
or <200 copies/mL

Analyses accounted for clustering, unequal
selection probabilities, and non-response

Mean stigma scores compared by sociodemographic, behavioral, and clinical outcomes using
one-way ANOVA (p<0.05)
Mean Stigma Score
Stigma measured by the modified 6-item
Internalized AIDS-Related Stigma Scale1
• Disagree=0; Neutral=0.5, Agree=1
• Summed; Range: 0 (low) – 6 (high)
Table 4. Comparison of Logistic Regression Models Predicting Durable Viral
Suppression Accounting for Stigma and ART Use and Adherence, MMP 2011
Model 1:
Stigma only
OR (95%CL)
Model 2:
ART use &
adherence only
OR (95%CL)
Model 3:
Stigma and ART
use & adherence
aOR (95%CL)
0.96*
(0.92, 0.99)
-
0.97
(0.93, 1.01)
ART Use & Adherence
Not on ART v. Adherent
-
Not Adherent v. Adherent
-
0.09**
(0.06,0.12)
0.44**
(0.36, 0.55)
0.09**
(0.06, 0.12)
0.45**
(0.36, 0.56)
4
3
Stigma
2
1
p=0.36
0
Not on ART

Multivariable model predicting durable viral
suppression accounting for stigma and ART adherence
p<0.0001
On ART, Adherent
ART Adherence
On ART, Not
Adherent
*p<0.05;**p<0.01
1Kalichman
SC, Simbayi LC, Cloete A, Mthembu PP,
Mkhonta RN, Ginindza T. Measuring AIDS stigmas in
people living with HIV/AIDS: The internalized AIDSrelated stigma scale. AIDS Care, 2009; 21(1):87-93.
www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Division of HIV/AIDS Prevention
RESULTS

75.6% of HIV-infected adults in care endorsed ≥1
HIV-related stigma question
• Over half reported difficulty telling people
about their HIV status and hiding their HIV
status from others
 Stigma was related to depression, binge drinking,
and non-disclosure of HIV status to sex partners
 The association of stigma with durable viral
suppression may be mediated by ART adherence
•
After adjusting for ART adherence, stigma
was no longer associated with durable viral
suppression
LIMITATIONS

Self-reported measures can yield recall and
desirability biases
 Limited to internalized HIV-related stigma, which
does not capture all aspects of stigma
 Response rate was lower than ideal, but estimates
were adjusted for non-response
 Results may not be generalizable to HIV-infected
patients not in care
CONCLUSIONS

Internalized HIV-related stigma was common
among persons receiving HIV care in the U.S.
 The mediating effect of adherence on the
association between stigma and durable viral
suppression should be explored
 Efforts to reduce depression and binge drinking
among HIV-infected persons could benefit from
information addressing internalized HIV-related stigma
 Community-level stigma reduction efforts may
help address stigma on a broader scale
ACKNOWLEDGEMENTS
We would like to thank MMP participants and staff for their
contributions. MMP is funded by the CDC.
This analysis was supported in part by an appointment to the
Internship/Research Participation Program at the CDC, U.S.
Environmental Protection Agency, administered by the Oak Ridge
Institute for Science and Education through an interagency
agreement between the U.S. Department of Energy and EPA.
CONTACT
Amy Baugher, MPH
ORISE Fellow
+1-(404)-639-1956
[email protected]