Women living with HIV (WLWH) and with histories of injection drug use experience worse health outcomes than other WLWH. HIV stigma has been consistently identified as a factor that negatively impacts HIV clinical and mental health outcomes. HIV stigma is associated with low CD4 and unsuppressed viral load, late clinical stage of disease presentation, low self-reported health status, poor medication adherence, increased depressive symptoms and stress. The HIV Stigma Framework defines HIV stigma as a social phenomenon that affects individuals living with HIV via a series of HIV stigma mechanisms, or distinct psychological responses to the knowledge that they possess a socially devalued characteristic (e.g., HIV positive), including internalized, anticipated, and enacted stigma. However, stigma is a complex, multi-layered phenomenon associated with other marginalized behaviors and identities. Layered stigma refers to the multiple stigmas that women often face due to HIV status, drug use, and gender, among others; layered identities interact with each other and cannot be understood in isolation or in a purely additive way. This study will use Latent Class Analysis (LCA), a well-accepted inductive statistical method that provides data-derived classifications of behaviors based on discrete variables, and qualitative, in-depth interviews to empirically characterize patterns of HIV, drug use, and gender-based stigma among WHLH who use drugs in order to provide a more sophisticated perspective on the intersection between layered stigmas, mental health, and engagement in HIV care. This study will be conducted among 300 WLWH with histories of drug use in Ukraine, where among women in Ukraine who indicated injection drug use as their mode of infection, the median delay between diagnosis and registration in care was 87 days, compared to 34 days for women diagnoses through antenatal testing.
The Specific Aims of this study are to 1) empirically identify and characterize patterns of layered stigma (HIV, drug use, and gender-based) among drug using WLWH in Ukraine; 2) examine the relationship between patterns of layered stigma identified through LCA and mental health outcomes and engagement in HIV care; and 3) qualitatively explore the association between layered stigma class, mental health, and engagement in HIV care. Unlike previous studies, which have focused on a single type of stigma (e.g., HIV, drug use, or gender only), this study will examine stigma as a layered phenomenon that WLWH who use drugs experience. Identifying and defining these subgroups of WLWH improves specification of women not engaged in care, and can lead to more efficient allocation of HIV care and mental health resources. Results from the LCA combined with the findings from the in-depth interviews about personal experiences of layered stigma will enable us to develop targeted, multi-pronged interventions to improve mental health and HIV clinical outcomes.
The proposed R21 study addresses a highly relevant public health question: how HIV, drug use, and gender stigma affect engagement in HIV care among women living with HIV with histories of drug use in Ukraine. Ukraine continues to experience one of the highest HIV rates in Eastern Europe, and HIV among women is a significant and understudied public health problem. The information gained through this study has the potential to inform the development of targeted, multi-pronged interventions to improve mental health and HIV clinical outcomes among a highly vulnerable population.
