The role of HIV stigma and discrimination on the health and HIV- protective behaviors of people living with HIV in Rio de Janeiro, Brazil Deanna Kerrigan, PhD, MPH Department of Health, Behavior, and Society Johns Hopkins Bloomberg School of Public Health

Stigma, Discrimination, HIV-Behaviors and Outcomes Stigma and Discrimination are recognized as barriers to protective HIV-related behaviors and health outcomes e.g. access to HIV counseling & testing, HIV treatment, HIV medication adherence and overall well-being and quality of life of PLHIV Recently greater attention has been paid to the “layered” nature of stigma including the ways in which multiple forms of social stigmas and inequalities underlie and are associated with HIV stigma, discrimination & human rights violations

Stigma as a Socio-Structural Process Stigma and discrimination related to HIV is understood here as a social process which produces and reproduces social divisions, hierarchies and unequal social structures: –Sexual Orientation –Gender –Race/Ethnicity –Class

Intersections of HIV-related Stigma & Underlying Social Stigmas and Inequalities Parker R. and Aggleton P. (2002) HIV/AIDS- related stigma and discrimination: a conceptual framework and an agenda for action. Population Council: Horizons Project.

Specific Aims –To examine the relationship between HIV stigma and discrimination and protective health behaviors and outcomes among a diverse sample of PLHIV attending public clinics in Rio de Janeiro, Brazil Reported health, care adherence, HIV medication adherence, consistent condom use, and reported STIs since diagnosis –To assess how other forms of underlying social stigmas intersect with HIV stigma and discrimination among a diverse sample of PLHIV attending public clinics in Rio de Janeiro, Brazil Gender, sexual orientation, income, race/ethnicity, sex work, drug use, incarceration

Brazilian Context Brazil is leader in rights-based HIV prevention, treatment & care: First lower to middle income country to establish universal access to treatment Battle against stigma and discrimination central to national response to HIV in Brazil Relatively limited research on HIV stigma and discrimination among PLHIV in Brazil

Study Setting, Population & Sampling Strategy Government-run public health clinics providing treatment and care to PLHIV in Rio de Janeiro Clinics (6/22) selected to ensure social and geographic diversity within greater Rio area Sample of 900 PLHIV –Specific targets to capture demographic characteristics and diversity of clinics –Gender, sexual orientation, and % on ARVs

Methods Structured survey to assess psychosocial and structural factors associated with HIV behaviors and health outcomes among participating PLHIV –Approximately 1 hour, private setting at clinic STI screening: Syphilis, Gonorrhea, Chlamydia –FTA-ABS syphilis & PCR analysis for GC Medical Record Extraction: CD4 count, viral load, opportunistic infections, hospitalizations

Measures Aggregate Measures & Items Mean & Range Reliability (Cronbach’s Alpha) HIV Discrimination: 8 items (e.g. I lost my job because of HIV) ( ).7488 HIV Stigma: 8 items (e.g. I feel guilty because of HIV) ( ).7545 Berger HIV Stigma Scale Likert scale 1-4 (strongly agree to strongly disagree) Minority of participants reported HIV stigma and discrimination

Primary Outcome Variables Reported good physical health last 6 months: 66.9% No missed HIV appointments last 6 months: 62.2% Took all ARV medications last 4 days: 83.5% Consistent condom use last 6 months: 67.7% Number of sexual partners: 0 (26%), 1 (48%), 2 or more (26%) Reported STI since HIV diagnosis: 19.7% Documented STI at time of survey: 6.9%

Data Analysis Approach Factor and reliability analysis for aggregate measures Univariate exploration of the distribution and normalcy of all variables and aggregate measures Bivariate and multivariate logistic regression analyses conducted for each of the study outcomes of interest Adjustments to standard errors of multivariate regression coefficients for clinic intra-class correlation

Characteristics of Sample Majority male (67%), 32% female, 1% trans Majority heterosexual (59%), 32% bisexual, 8% homosexual Majority non-white Median age (41.0) Low education (primary)/income ($375/mo) 10% prior sex work 15% prior drug use 75% of sample on ARVs

Bivariate Analysis: HIV stigma and discrimination and protective health behaviors and outcomes among PLHIV Unadjusted Odds Ratios (95% CI) Physical health Missed treatment & care visits ARV adherence Consistent condom use STI since diagnosis Higher HIV Discrimination.58 ( ) *** 1.40 ( ) *.63 ( ) *.97 ( ) 1.7 ( ) ** Higher HIV Stigma.46 ( ) *** 1.43 ( ) **.60 ( ) *.81 ( ) 1.33 ( ) ***=p<.001; **=p<.01; *=p<.05

Multivariate Analysis: HIV stigma and discrimination and protective health behaviors and outcomes among PLHIV Adjusted Odds Ratios (95% CI) Physical Health Missed Treatment & care appointments ARV adherence STI since diagnosis Higher HIV Discrimination.71 ( )* (p=.029) 1.24 ( ) (p=.154).71 ( ) (p=.127) 1.63 ( )* (p=.008) Higher HIV Stigma.54( )*** (p=.000) 1.26 ( ) (p=.121).70 ( ) (p=.122) 1.25 ( ) (p=.223) ***=p<.001; **=p<.01; *=p<.05; Controlling for socio-demographic and behavioral characteristics significant in bivariate analysis

Factors Associated with HIV Stigma and Discrimination FactorsHigher HIV StigmaHigher HIV Discrimination Female/Transgender 1.35 ( ) * 1.28 ( ) Homo-bisexual.71 ( ) **.83 ( ) Age: 42 or older.68 ( ) **.65 ( )**.70 ( )**.72 ( )* Non-White1.46 ( )1.18 ( ) > Primary school.58 ( )***.71 ( )*.91 ( ) Pentecostal religion 1.53 ( ) * 1.48 ( )* No regular partner1.12 ( ) 1.31 ( )* One or > child(ren) 1.63 ( ) *** 1.65 ( )** 1.10 ( ) Income: > 600 R.60 ( ) ***.74 ( )*.61 (.47.80)***.62 ( )** No prior sex work.52 ( ) **.56 ( )*.60 ( )* No prior drug use.69 ( ).62 ( )*.63 ( )* Not on ARVs.95 ( )1.38 ( )* 1.56 ( )** ***=p<.001; **=p<.01; *=p<.05;

Discussion HIV stigma and discrimination are relatively low among PLHIV attending public clinics in Rio de Janeiro, Brazil Significant associations documented in multivariate analyses between HIV-related stigma and discrimination and reported physical health as well as HIV-related discrimination and reported STIs since diagnosis HIV stigma and discrimination are associated with underlying social stigmas and inequalities e.g. poverty, sex work, drug use and are greater among younger people Being on ARVs is protective against HIV discrimination

Conclusions Findings from this study indicate the importance of addressing multiple, overlapping social stigmas among PLHIV to improve their health and well-being and reduce ongoing HIV transmission Brazil has led the way in combating HIV stigma and discrimination, however, challenges still exist particularly among marginalized population groups Socio-structural interventions focused addressing the multiple dimensions of stigma and discrimination experienced by PLHIV particularly those from marginalized groups are needed Evaluations of multi-level interventions to promote linkages to care, protective HIV-related behaviors and reduce HIV/STI transmission

Acknowledgements Co-investigators: Francisco Bastos, MD, Monica Malta, PhD,Neilane Bertoni, MPH, Oswaldo Cruz Foundation, The Rio Collaborative Group Thanks to study participants, clinic personnel, the study team and to the Ford Foundation