Author

Tianyue Mi

Date of Award

Summer 2022

Document Type

Open Access Dissertation

Department

Health Promotion, Education and Behavior

First Advisor

Xiaoming Li

Second Advisor

Shan Qiao

Abstract

Background: Many men who have sex with men (MSM) living with human immunodeficiency virus (HIV) experience suboptimal health outcomes compared to nonMSM males living with HIV, including a faster decline in CD4 count before initiating antiretroviral therapy (ART), slower immune recovery after initiating ART, more mental health problems, suboptimal ART adherence, and lower retention in care. MSM living with HIV are often exposed to multiple layered stigmas, including, but not limited to, stigma related to being infected with HIV and stigma related to sexual and gender minority (SGM) status. Although various scales of HIV-related stigma have been frequently used for comparisons between MSM and non-MSM males, no evidence has shown that these scales measure the same constructs between the two groups. In addition, most studies of health disparities between MSM and non-MSM males and the role of intersectional stigma were cross-sectional studies conducted in the United States. This dissertation research examined the measurement invariance for scales of some common types of HIV-related stigma (i.e., internalized, anticipated, and enacted HIV-related stigma) between MSM and non-MSM males living with HIV, investigated longitudinal pattern of disparities in health outcomes between the two groups, and explored how HIVrelated stigma and SGM-related stigma intersect to be associated with health outcomes among MSM living with HIV in resource-limited settings in China.

Methods: Data were derived from a prospective cohort study among 1,198 people living with HIV (772 men and 426 women) and a cross-sectional study among 402 MSM living with HIV, both in Guangxi, China. Assessments were conducted at baseline from November 2017 to February 2018 and at 6-, 12-, 18-, 24-, 30-, and 36-month follow-ups for the prospective cohort study, and from August 2020 to May 2021 for the crosssectional study. Demographic information, stigma, HIV-related characteristics, physical (e.g., CD4 count, viral load), psychological (e.g., depressive symptoms, anxiety symptoms), and behavioral (e.g., ART adherence) outcomes were collected in both studies. Confirmatory factor analyses, latent growth curve modeling, and latent moderated structural equations were employed to examine measurement invariance (i.e., configural, metric, scalar, and residual invariance) of HIV-related stigma scales between MSM and non-MSM males, disparities of health outcomes trajectories between the two groups, and the effect of intersectional stigma on health outcomes among MSM living with HIV, respectively.

Results: Configural and metric invariances were fully satisfied, and scalar invariance was partly satisfied for the internalized and enacted HIV-related stigma scales. Configural, metric, and scalar invariances were fully satisfied, and residual invariance was partly satisfied for the anticipated HIV-related stigma scale. Results provided evidence for acceptable measurement invariance for the HIV-related stigma scales between MSM and non-MSM males. The trajectories of CD4 count, viral load, and ART adherence differed between MSM and non-MSM males, but such differences disappeared after controlling for baseline sociodemographic covariates. The interactive effects between HIV-related stigma and SGM-related stigma on depressive and anxiety symptoms were significant among MSM living with HIV. When SGM-related stigma was low, the associations between HIV-related stigma and depressive/anxiety symptoms were not significant; when SGM-related stigma was high, such associations were significantly positive.

Conclusion: This dissertation research suggested that the internalized, anticipated, and enacted HIV-related stigma scales should be used with caution for comparison studies between MSM and non-MSM males. Differences between MSM and non-MSM males in physical, psychological, and behavioral health trajectories provided important contributions to understanding the well-being of stigmatized minorities by highlighting intersectional stigma as a mechanism of adverse health outcomes and health inequities between MSM and non-MSM males in China. The studies will inform future stigma reduction interventions that consider the synthetic effects of multiple sources of stigma.

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