AIDS Behav
DOI 10.1007/s10461-015-1164-1
SUBSTANTIVE REVIEW
The Association of HIV-Related Stigma to HIV Medication
Adherence: A Systematic Review and Synthesis of the Literature
Shannon M. Sweeney1 • Peter A. Vanable1
Ó Springer Science+Business Media New York 2015
Abstract This paper provides a review of the quantitative
literature on HIV-related stigma and medication adherence,
including: (1) synthesis of the empirical evidence linking
stigma to adherence, (2) examination of proposed causal
mechanisms of the stigma and adherence relationship, and
(3) methodological critique and guidance for future
research. We reviewed 38 studies reporting either cross-
sectional or prospective analyses of the association of HIV-
related stigma to medication adherence since the intro-
duction of antiretroviral therapies (ART). Although there is
substantial empirical evidence linking stigma to adherence
difficulties, few studies provided data on psychosocial
mechanisms that may account for this relationship. Pro-
posed mechanisms include: (a) enhanced vulnerability to
mental health difficulties, (b) reduction in self-efficacy, and
(c) concerns about inadvertent disclosure of HIV status.
Future research should strive to assess the multiple
domains of stigma, use standardized measures of adher-
ence, and include prospective analyses to test mediating
variables.
Resumen Este artı́culo ofrece una revisión de la litera-
tura cuantitativa sobre el estigma relacionado con el VIH y
la adherencia a la medicación, incluyendo: (1) la sı́ntesis de
la evidencia empı́rica que une el estigma a la adhesión, (2)
el examen de los mecanismos causales propuestas de la
relación estigma y la adhesión, y (3) crı́tica metodológica y
& Shannon M. Sweeney
smsweene@syr.edu
Peter A. Vanable
pvanable@syr.edu
1
Department of Psychology, Syracuse University, 430
Huntington Hall, Syracuse, NY 13244-2340, USA
orientación para futuras investigaciones. Se revisaron 38
estudios que informaron los análisis bien transversales o
potenciales de la asociación de estigma relacionado con el
VIH a adherencia a la medicación desde la introducción de
los tratamientos antirretrovirales (TAR). Aunque no existe
evidencia empı́rica sustancial que une el estigma a la
adherencia dificultades, pocos estudios proporcionaron
datos sobre los mecanismos psicosociales que pueden
explicar esta relación. Los mecanismos propuestos inclu-
yen: (a) la vulnerabilidad mejorado para problemas de
salud mental, (b) la reducción de la autoeficacia, y, (c) las
preocupaciones sobre la divulgación inadvertida de la
condición de VIH. Las investigaciones futuras deberı́an
esforzarse por evaluar los múltiples dominios de estigma,
utilizar medidas estandarizadas de la adhesión, e incluyen
análisis prospectivos para evaluar variables mediadoras.
Keywords HIV
Stigma
Medication adherence

Antiretroviral therapy
Palabras clave VIH
el estigma
la adherencia a la
medicación
la terapia antirretroviral
As of 2012, an estimated 35 million people worldwide
were living with HIV, and an estimated 2.3 million people
became newly infected that year [1]. Since the introduction
of antiretroviral therapies (ART), HIV-positive individuals
with access to medical care are able to lead longer lives,
turning a once fatal diagnosis into a more manageable
chronic illness [2, 3]. Although great strides have been
made, people living with HIV (PLWH) still encounter
powerful stressors, one of which is the widespread social
stigma associated with HIV. Over 30 years since the
beginning of the epidemic, stigma continues to persist
worldwide, representing a formidable challenge for PLWH
123

[1, 4]. A recent review found that PLWH on ART expe-
rience some type of stigma, with prevalence rates from
42 % in high income countries to 82 % in low and middle
income countries [5].
Stigma is defined as a discrediting attribute that reduces
a whole or usual person to a tainted, discounted person [6].
HIV-related stigma is considered a particularly complex
phenomenon, given its associations with already
marginalized behaviors, including injection drug use, sex-
ual promiscuity, and homosexual behavior [7, 8]. Three
different types of HIV-related stigma are presumed to
impact PLWH [9]. Anticipated stigma involves expecta-
tions of discrimination, stereotyping, and/or prejudice from
others in the future due to one’s serostatus. Similarly,
enacted stigma involves experiences of discrimination,
stereotyping, and/or prejudice from others that have
already occurred. Finally, internalized stigma refers to self-
endorsing negative feelings and beliefs about having HIV.
These three types are considered to be conceptually related
but distinct constructs [9–11].
Research that informs our understanding of the conse-
quences of HIV-related stigma is important, as there can be
far-reaching consequences. Stigma has consistently been
associated with a number of mental health difficulties in
cross-sectional and prospective analyses, including
increased levels of anxiety, depression, and hopelessness,
as well as decreases in self-esteem [12–18]. In addition,
PLWH may face social consequences, such as negative
social interactions [19] or loss of social support [17]. A
recent meta-analysis found a moderate relationship
between increased stigma and decreased social support, as
well as increased stigma and decreased disclosure [20].
Both enacted and internalized stigmas have been found to
reduce available instrumental and emotional social support
[21]. At the same time, availability of instrumental and
emotional social support may also buffer the effects of
enacted and internalized stigmas [21].
The experience of stigma may also be detrimental to the
physical health of PLWH and interfere with their ability to
manage the disease, including delayed or avoidance of HIV
testing [22–25] and poor engagement in care [26, 27]. A
recent meta-analysis concluded that HIV-related stigma is
associated with several physical health indicators, includ-
ing AIDS-related symptoms, clinical stage of the disease,
and self-reported physical health [17]. Most importantly,
HIV-related stigma may also interfere with ability to
adhere to challenging medication regimens, which require
strict adherence in order to decrease viral load (VL) and
increase CD4 counts [28, 29]. Without near perfect
adherence, PLWH risk treatment failure and possible
development of resistant virus [30–33]. Unfortunately,
poor treatment adherence continues to be common among
PLWH [34]. A recent meta-analysis found an average of
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AIDS Behav
62 % of participants reported C90 % adherence to ART
[35].
Research has focused on identifying barriers to adher-
ence for PLWH. One barrier to adherence that is gaining
increasing attention in the literature is stigma. For PLWH,
taking medication may require consumption at inopportune
times and in public environments. Fear or anxiety over
inadvertent disclosure of HIV status may result in delayed
or skipped doses [36, 37]. Stigma may also enhance vul-
nerability to mental health difficulties such as depression
[16, 17], which in turn may lessen motivation to maintain
optimal health through adherence [37]. Thus, stigma may
serve as a significant barrier to adherence for PLWH.
Existing reviews on the phenomenon of stigma under-
score its effects on mental health and quality of life [16,
38], as well as its impact on management of HIV disease
[39]. More recently, a review on stigma, disclosure, and
medication adherence has been published [40]. However,
no existing review focuses exclusively on the quantitative
literature on stigma and adherence. Further, no review
exists that isolates the critical question of what causal
mechanisms may account for a relationship between stigma
and adherence. Accordingly, this review sought to provide
a focused synthesis and critique of the quantitative litera-
ture on HIV-related stigma and HIV medication adherence.
To achieve this aim, this paper (1) synthesizes research
findings regarding direct associations between stigma and
adherence and (2) discusses proposed causal mechanisms
of the stigma and adherence relationship, including an
examination of studies that have empirically tested these
mechanisms. Following the review, a methodological cri-
tique and clear guidance for future research are provided.
Search Strategy and Study Selection
The systematic review was conducted and reported in
accordance with PRISMA [41]. PsycINFO, PubMED, Ovid
MEDLINE, and Web of Science databases were searched
for English-language articles that tested associations
between HIV-related stigma and HIV medication adherence
in samples of PLWH. Databases were searched from Jan-
uary 1, 1997 up until December 31, 2014. Search terms for
HIV included ‘‘HIV,’’ ‘‘AIDS,’’ ‘‘HIV/AIDS,’’ and ‘‘human
immunodeficiency virus.’’ For antiretroviral therapy, terms
included ‘‘antiretroviral therapy,’’ ‘‘highly active antiretro-
viral therapy,’’ ‘‘HAART,’’ ‘‘ART,’’ and ‘‘ARV.’’ For
adherence, terms included ‘‘medication adherence,’’
‘‘medication compliance,’’ ‘‘medication,’’ ‘‘adherence,’’ and
‘‘compliance.’’ Finally, terms for stigma included ‘‘stigma’’
and ‘‘stigmatization.’’
Figure 1 summarizes the search results that yielded
3835 articles from searching the four databases. Three
AIDS Behav

Idenficaon
Records idenfied through Addional records idenfied
database searching through other sources
(n = 3835 ) (n = 3 )

Records aer duplicates removed

(n = 2409 )
Screening

Records screened Records excluded

(n = 2409 ) (n = 2022 )

Full-text arcles excluded

Eligibility

Full-text arcles assessed

n = 341 (did not report or
for eligibility
test quantave results)
(n = 387 )
n = 4 (quantave results
from intervenon study)
n = 2 (duplicate data)
n = 2 (no access)

Studies included in
Included

quantave synthesis
(n = 38 )

Fig. 1 Flow diagram. We identified 3835 records by searching four databases, yielding 38 quantitative studies

additional studies that met the inclusion criteria were found differed, so both were retained for the review. An addi-
through a manual search of the reference sections from tional two studies [44, 45] reported on the same dataset, but
relevant studies. Titles and abstracts were reviewed, and different adherence outcomes were used in analyses, so
387 articles were retained for full paper screening. Articles both were retained.
were included if they met all of the following criteria:
1. Consisted of original, quantitative research published
Review of the Literature
in a peer-reviewed journal.
2. Assessed stigma related to the participant’s HIV-
Review of the Association Between HIV-Related
positive status.
Stigma and HIV Medication Adherence
3. Assessed participant’s adherence to HIV medication.
4. Reported on a statistical test for the association
The primary aim of this review is to characterize study
between stigma and adherence.
findings from research examining the association of stigma
5. Analyses used were not within the context of an
and medication adherence among PLWH. First, this por-
intervention study designed to improve adherence,
tion of the review focuses on direct associations between
unless analyses reported were taken from baseline data
stigma and adherence outcomes. Second, we discuss pro-
only.
posed causal mechanisms of the relationship between
According to these criteria, 38 studies satisfied the stigma and adherence, as the understanding of causal
above search criteria. Two of these studies [42, 43] mechanisms will help guide future research. In this dis-
reported on the same univariate stigma and adherence cussion, we also review studies that have empirically tested
outcomes. However, multivariate and mediational analyses mediators of the stigma and adherence relationship.

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Direct Associations Between Stigma and Medication
Adherence
Of the 38 reviewed studies, two papers reported on the
same stigma and adherence outcomes. Thus, the review of
direct associations between stigma and adherence consists
of 37 distinct studies. First, the review is divided into
studies that used single (n = 29) and multiple (n = 8)
measures of stigma in multivariate analyses. Assessing
multiple domains of stigma simultaneously may elucidate
unique associations with adherence. Second, studies are
categorized based on the type of stigma measured. Asso-
ciations were examined using the three types of stigma
delineated by Earnshaw and Chaudoir [9], which include
internalized, enacted, and anticipated stigmas. Examining
associations by measurement type may clarify whether the
effects of stigma on adherence vary as a function of the
conceptualization of stigma.
Studies that Combined Multiple Dimensions of Stigma
As indicated in Table 1, 15 of the studies yielded through
our search used a single measure that included items
assessing multiple domains of stigma, but analyses treated
the measure as a unidimensional scale. The most frequently
used measure was an original or modified version of Ber-
ger’s HIV Stigma Scale [46–51], which includes four
subscales of personalized stigma, disclosure concerns,
negative self-image, and concern with public attitudes. In
other investigations, stigma was assessed through a variety
of instruments including the HIV Internalized Stigma
Measure [52, 53], HIV/AIDS Stigma Instrument-PLWA
[54], Self-Stigma Scale [55], HIV/AIDS-related Stigma
and Discrimination [56], Stigma Scale for Chronic Illness
[57], and items selected from the Patient Medication
Adherence Questionnaire [52]. These instruments are
characterized by a range of subconstructs, including
internalized (e.g., negative self-perception), anticipated
(e.g., renegotiating social relationships), and enacted (e.g.,
healthcare discrimination) stigmas. A combination of
enacted and anticipated stigma items was used for two
studies [44, 45], but the exact stigma measure used was not
mentioned.
Taken together, the studies that used combined mea-
sures of stigma are supportive of an association between
overall stigma and adherence difficulties in PLWH. Six
investigations found that stigma was significantly associ-
ated with poor self-reported adherence at the multivariate
level, after adjusting for factors such as demographics,
perceived health, structural barriers, and alcohol and drug
use [42, 44, 45, 47, 49, 56]. Two prospective investigations
lent support to this association as well. In Dlamini et al.’s
investigation with PLWH in five African countries,
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participants who were adherent had lower stigma scores at
baseline and experienced a steeper decline in stigma over
time than participants who were non-adherent [54]. Addi-
tionally, in a sample of Chinese PLWH, Mo and Mak
demonstrated that higher stigma scores at baseline pre-
dicted intentional nonadherence, compared to adherence
and unintentional nonadherence, at 6-month follow up
[55].
Additional studies using combined measures of stigma
have identified distinctions between univariate and multi-
variate analyses. Specifically, whereas Cardarelli et al.
[46], Rao et al. [57], Sayles et al. [53], and Tyer-Viola et al.
[51] all found significant univariate associations between
stigma and self-reported adherence among PLWH, these
associations diminished to non-significance at the multi-
variate level, with other factors including mental health
symptoms, depressive symptoms, and perceived general
health status emerging as significant predictors. In another
investigation [52], a combined stigma measure composed
of four subscales (i.e., stereotypes of HIV, disclosure
concerns, renegotiating social relationships, self-accep-
tance) was associated with adherence in univariate analy-
ses, but adherence failed to predict any of the individual
stigma subscales at the multivariate level. Instead,
depression, social support, and attitudes toward providers
and antiretroviral medications emerged as significant pre-
dictors of many of these stigma subscales. Finally, Klein-
man et al. [48] and Martinez et al. [50] reported no
univariate associations between stigma and adherence.
Studies Focusing on Internalized Stigma
Four studies assessed internalized stigma, or self-endorsed
negative feelings and beliefs associated with having HIV.
Internalized stigma was assessed using the Internalized
AIDS Stigma Scale [58, 59], Perceived Stigma of HIV/
AIDS Scale [60], and internalized stigma items developed
from previous research [61]. Findings from these studies
provided mixed support for a direct association between
internalized stigma and adherence. An investigation by
DiIorio et al. [60] found that internalized stigma was
indirectly related to adherence difficulties in a structural
equation model, which also included self-efficacy,
depression, social support, and patient satisfaction.
Kalichman et al. [58] found a significant univariate asso-
ciation between stigma and adherence, as assessed by
unannounced pill counts at 1-month follow up, but the
association disappeared in multivariate analyses, after
controlling for social and poverty-related stressors, drug
use, and depression. Similarly, Li et al. [61] demonstrated
that internalized stigma was associated with self-reported
adherence in univariate analyses, but the association
diminished to non-significance in multivariate analyses,
 Table 1 Overview of quantitative studies examining the association between HIV-related stigma and HIV medication adherence among PLWH
Author Publication Study design and population Type of Stigma measurement Adherence measurement Core findings
year characteristics stigma
AIDS Behav

Achappa 2013 Cross-sectional study of 116 Unclear Unclear questions assessing Self-reported missed doses over Stigma was associated with non-
et al. [69] adults (60 % male) recruited stigma past 4 days using ACTG adherence
from a hospital in Mangalore, Adherence Instrument [99]. Low
South India adherence defined as \95 %
doses
Boyer et al. 2011 Cross-sectional study of a sub- Enacted Personal experience of HIV- 14-item questionnaire [100] Stigma was associated with non-
[63] sample of 2381 outpatients in related stigma from partner or related to dose taking and dosing adherence (AOR = 1.74, 95 %
27 hospitals located in close family members time schedule. Non-adherence CI = 1.14–2.65) in multilevel
Cameroon defined as \100 % of prescribed logistic models, controlling for
doses in both the past 4 days and other individual and healthcare
4 weeks, but no treatment supply-related factors
interruptions lasting [2
consecutive days
Cardarelli 2008 Cross-sectional study of 103 Combined 40-item HIV Stigma Scale 6-item simplified medication Stigma was not associated with
et al. [46] adults (white, African (a = .96) [101] adherence questionnaire [102] non-adherence (AOR = 1.01;
American, and/or Hispanic/ related to forgetfulness or 95 % CI = 0.98–1.03) in
Latino) at a preventive carelessness in taking multivariate regression analyses
medicine clinic in Texas medications (a = .75). Non-
adherence defined as a positive
screen
Carlucci et al. 2008 Cross-sectional study of 424 Unclear Unclear measure concerning Pill count measured over a median Stigma was not associated with
[71] adults at a rural mission ‘‘perceived sources of stigma’’ of 84 days. Non-adherence non-adherence (AOR = 1.1,
hospital in Zambia defined as \95 % of prescribed 95 % CI = 0.55–2.1) in
doses multivariate logistic regression
analyses
DiIorio et al. 2009 Cross-sectional study of 236 Internalized Four items from the Perceived Five items related to logistical Using structural equation
[60] adults (87 % black) recruited Stigma of HIV/AIDS Scale problems with remembering to modeling, self-efficacy was
from an HIV clinic in Atlanta (a = .77) [103] take meds over past 30 days supported as a mediator between
from the ACTG Adherence stigma and adherence, but
Instrument (a = .86) [99]. depression was not supported
Fewer problems indicated
greater adherence
Dlamini et al. 2009 Prospective study of 698 adults Combined 33-item HIV and AIDS Stigma Nine items related to reasons for At baseline, stigma was higher in
[54] in Lesotho, Malawi, South Instrument-PLWA (a = .94) missing meds over past 30 days those who had missed at least
Africa, Swaziland, and [104] from the ACTG Adherence one dose compared to those who
Tanzania Instrument-Rev (a = .96) [99, had missed no doses. Using
105]. Scores dichotomized into multilevel growth modeling,
those missing at least one dose those who reported not missing
and those missing no doses any doses experienced a steeper
decline in stigma over time, after
including health worries,
symptoms, and social support

123
 Table 1 continued
Author Publication Study design and population Type of Stigma measurement Adherence measurement Core findings
year characteristics stigma

123
Earnshaw 2013 Cross-sectional study of 95 Internalized; Items were adapted from Two items from Swiss HIV In a multivariate regression model,
et al. [72] adults recruited from an anticipated; previously validated scales [101, Cohort Study [107]. Non- internalized stigma was
inner-city HIV clinic in the enacted 106]. Included three scales: adherence defined as missed marginally associated with non-
Bronx, NY 6-item internalized (a = .89), dose in past 4 weeks and/or adherence (OR = 1.73, 95 % CI
9-item anticipated (a = .87), missed two consecutive doses in 0.97–3.08), while anticipated
and 9-item enacted (a = .87) past 4 weeks stigma (OR = 0.90, 95 % CI
0.44–1.84) and enacted stigma
(OR = were not associated
Halkitis et al. 2014 Cross-sectional study of 199 Combined 15 items from the HIV Stigma Four items from the ACTG Stigma was associated with
[47] aging MSM recruited from Scale (a = .92) [101] Adherence Instrument [99]. missed doses in past 4 days
the community in NYC Items assessed missed doses in (AOR = 1.04, 95 %
past 4 days, taking doses outside CI = 1.00–1.09) and failing to
specified schedule in past follow instructions
4 days, failing to follow (AOR = 1.06, 95 %
instructions in past 4 days, and CI = 1.00–1.11), after
missed doses in most recent controlling for age and
weekend. Overall adherence education. Stigma was
score also created (range: 0–4) associated with overall
adherence score (r = 0.24) in
bivariate analyses
Kalichman 2010 Prospective study of 188 adults Internalized 7-item Internalized AIDS Stigma Two unannounced telephone- Stigma was associated with non-
et al. [58] with poor literacy recruited Scale (a = .86) [108] based pill counts over 21- to adherence in bivariate analyses
from service organizations, 35-day interval. Non-adherence (OR = 0.52, 95 % CI
healthcare providers, social defined as \85 % of doses taken 0.30–0.91). After controlling for
service agencies, and social stressors, depression, drug
infectious disease clinics in use, and poverty-related stress,
Atlanta stigma was no longer associated
with non-adherence
(OR = 1.07, 95 % CI
0.48–2.40)
Kekwaletswe 2014 Cross-sectional study of 304 Combined Sum of scores across two enacted Four self-report items assessing Lower stigma was associated with
and patients (68 % women) at two stigma items and two anticipated medication taking associated ‘‘simultaneous ART taking
Morojele district hospitals in Tshwane, stigma items with drinking alcohol while drinking,’’ (B = -0.20)
[44] South Africa after controlling for education
and wealth. Higher stigma was
associated with ‘‘skipping ART
taking while drinking,’’
(B = 0.18) after controlling for
alcohol use
AIDS Behav
 Table 1 continued
Author Publication Study design and population
year characteristics
Kingori et al. 2012 Cross-sectional study of 370
[78] adults (61 % female)
recruited from urban HIV
clinic in Kenya
Kleinman 2014 Cross-sectional study of 151
et al. [48] adults recruited from HIV-
support groups in India
Levi-Minzi 2014 Cross-sectional study of 503
et al. [52] substance abusing individuals
(68 % black) in South
Florida, half of whom were
selling or trading ARV
medications
Li et al. [61] 2010 Cross-sectional study of 386
adults (67 % women)
recruited from four district
hospitals in northern and
north-eastern Thailand
Li et al. [56] 2011 Cross-sectional study of 202
outpatients enrolled in the
Chinese national free ART
program, selected from three
HIV treatment sites in Hunan
Province, China
123
Type of Stigma measurement
stigma
Enacted; 18-item HIV Felt Stigma
combined Instrument (a = .86) [109].
Included four factors: public
attitudes, ostracize,
discrimination, and personal life
disrupted
Combined Administration of 40-item HIV
Stigma Scale [101], but
tabulated according to 25-item
adapted to South India [111]
Combined 11-item modified version of the
HIV internalized stigma measure
[113]. Included four subscales:
stereotypes about HIV
(a = .72), self-acceptance
(a = .69), disclosure concerns
(a = .72), and social
relationships (a = .83)
Internalized 9-item internalized stigma scale
(a = .80) [114, 115]
Combined 34-item HIV-related stigma scale
(a = .90) [116]
Adherence measurement
Four items adapted from the
Morisky Medication-Taking
Adherence Scale [110], with no
specific recall period
Three single-item measures of
adherence were used: ACTG
(4 days), last missed dose
(7 days) [99], and VAS (7 days)
[112]. Non-adherence defined
as \100 % of prescribed doses
Used ACTG Adherence
Instrument [99] to assess missed
doses in the past 7 days. Non-
adherence defined as \95 % of
prescribed doses
Self-reported failure to adhere to
ART in past month. Non-
adherence defined as any missed
dose in past month
Adherence questionnaire from the
Community Programs for
Clinical Research on AIDS
Antiretroviral Medication Self-
Report [117]. Self-reported
missed doses over past 7 days
Core findings
AIDS Behav
Public attitudes (OR = 2.34,
95 % CI 1.24–4.40) and
personal life disrupted
(OR = 2.13, 95 % CI
1.22–3.68) were associated with
non-adherence, after controlling
for depression. Ostracize and
discrimination were not
associated in same model
In both bivariate and multivariate
analyses, no association between
stigma and adherence,
irrespective of measure used, nor
any association with stigma
subdomains (estimates not
shown). No evidence that
depression mediated stigma and
adherence relationship
In bivariate analyses, non-
adherence associated with higher
overall stigma, as well as in
relation to self-acceptance,
disclosure, and social
relationships. In multivariate
models, no significant
associations with adherence
when predicting stigma
subscales
In bivariate analyses, stigma was
associated with non-adherence
(r = -0.12, p \ 0.05). After
controlling for demographics,
depression, access to care,
disclosure, and family
functioning, stigma was no
longer associated (AOR = 0
0.83; 95 % CI 0.51–1.36)
Stigma was associated with non-
adherence (AOR = 0.96; 95 %
CI = 0.93–0.98), after
controlling for demographics,
drug use, and CD4 counts
 Table 1 continued
Author Publication Study design and population Type of Stigma measurement Adherence measurement Core findings
year characteristics stigma

123
Li et al. [49] 2014 Cross-sectional study of 128
adults from a government-
operated community hospital
in Chiang Mai, Thailand
Lyimo et al. 2014 Prospective study of 158 adults
[73] at two rural HIV clinics in
northern Tanzania
Martinez 2012 Prospective study of 178
et al. [50] females aged 15–24 years
recruited from NYC, Chicago,
Miami, Los Angeles, and
New Orleans
Mo and Mak 2009 Prospective study of 102 adults
[55] (89 % male) recruited from
an outpatient HIV clinic in
Hong Kong
Morojele 2013 Cross-sectional study of 304
et al. [45] patients (68 % women) at two
district hospitals in Tshwane,
South Africa
Musumari 2014 Cross-sectional study of 898
et al. [59] adults recruited from one
public health facility and
three private health
institutions in Kinshasa,
Democratic Republic of
Congo
Combined 10-item condensed version of HIV
Stigma Scale (a = .61) [101,
118]. Included: personalized
experience (a = .75), disclosure
(a = .73), negative self-image
(a = .84), and public attitudes
(a = .72)
Enacted; Adapted items from HIV Stigma
internalized Scale [101] and Internalized
AIDS-Related Stigma Scale
[108]. Included 5-item perceived
stigma scale (a = .76) and
5-item self-stigma scale
(a = .78)
Combined Administered disclosure concerns
and negative self-image
subscales of the HIV Stigma
Scale (a = .90) [101]
Combined 22-item self-stigma scale
(a = .87) [121]
Unclear Unclear measure of stigma
Internalized Internalized AIDS-Related Stigma
Scale (a = .60) [108].
Participants categorized as high
or low stigma
8-item version of the Morisky
Medication-Taking Adherence
Scale (a = .61) [110, 119, 120].
Adherence categorized as high,
medium, or low
Average of three self-reported
monthly adherence measures
(months 1, 3, and 5), which
assessed number of missed doses
over past month
Single item that asked participants
if they missed taking all doses of
meds any day over past 4 days.
Non-adherence defined
as \100 % doses
ACTG Adherence Instrument [99]
administered at 6-month follow-
up. Participants classified as
adherers, intentional non-
adherers, or unintentional non-
adherers based on reasons for
missing meds
CASE Adherence Index [122].
Three-item measure assessing
difficulty taking meds on time,
frequency of missed doses, and
time since most recent missed
dose. Scores summed and
categorized as ‘‘good’’ or
‘‘poor’’ adherence
Composite measure using both
pharmacy refill over past
6 months and self-reported
adherence questionnaire [123]
over past 7 days. Non-adherence
defined as \95 % doses on one
or both measures
Total stigma score was associated
with adherence (standardized
B = -0.328), p \ 0.001), after
adjusting for age and perceived
health
Self-stigma was associated with
non-adherence (B = -0.21,
p \ 0.05), after controlling for
demographics, disclosure,
religious coping, alcohol use,
and acceptance of HIV status.
Perceived stigma was not
associated in same model
In a binary logit regression model,
baseline stigma was not
associated with adherence at
12-month follow-up
(B = -0.01, p [ 0.50)
Intentional non-adherers had
higher stigma (M = 4.11, SD
0.74) than adherers (M = 3.78,
SD 0.96) and unintentional non-
adherers (M = 3.22, SD 0.92) F
[1, 100] = 7.58, p \ 0.001
Stigma was associated with poor
adherence (B = -0.17,
p \ 0.01), after including
demographics, structural factors,
disclosure, and alcohol use
In bivariate analyses, high stigma
was not associated with non-
adherence (OR = 1.12; 95 % CI
0.80–1.57)
AIDS Behav
 Table 1 continued
Author Publication Study design and population Type of Stigma measurement Adherence measurement Core findings
year characteristics stigma
AIDS Behav

Nachega et al. 2004 Cross-sectional study of 66 Anticipated Fear of stigma (rejection, ACTG Adherence Instrument In bivariate analyses, stigma was
[66] adults (71 % women) at an violence, or both) from sexual [99]. Self-reported missed doses associated with non-adherence
HIV clinic in Soweto, South partner over past month. Non-adherence (OR = 0.13, 95 %
Africa defined as \95 % doses CI = 0.02–0.70)
Negash and 2013 Cross-sectional study of 355 Unclear Unclear measures of internalized Self-reported missed doses in the In bivariate analyses, non-
Ehlers [70] adults at a hospital-based HIV stigma and perceived stigma past 7 days. Non-adherence adherence was associated with
clinic in Addis Ababa, defined as \95 % doses internalized stigma and
Ethiopia perceived stigma (OR estimates
not given)
Nozaki et al. 2011 Cross-sectional study of 518 Anticipated Perceived fear of stigma resulting Self-reported missed doses in the Stigma was associated with non-
[67] adults at district hospital or from taking ARVs at home or past 4 days. Non-adherence adherence in bivariate analyses
one of 4 rural health centers in work defined as \100 % of prescribed (OR = 2.3; 95 %
Mumbwa District, Zambia doses CI = 1.21–4.47). After
controlling for age, cost of return
trip, adherence support, ways to
remember to take meds, and
feeling pressured to share meds,
stigma was no longer associated
with non-adherence
(OR = 1.06; 95 %
CI = 0.41–2.75)
Nyamathi 2012 Cross-sectional study of 68 Heard stigma; Four stigma subscales [124]: Observation by pill count used to In bivariate associations, heard
et al. [79] women recruited from two Felt stigma; 10-item heard stigma (a = .85), measure adherence over past (r = 0.33, p \ 0.005) and
villages in rural Andhra enacted 10-item felt stigma (a = .84), month internalized (r = -0.23,
Pradesh, India stigma; 10-item enacted stigma p \ 0.049) stigma were
internalized (a = .90), and 10-item associated with non-adherence.
stigma internalized stigma (a = .89) In a separate hierarchical linear
regression model, neither was
associated with non-adherence,
after adjusting for depression
and adherence support from
parents
Omosanya 2014 Cross-sectional study of 100 Unclear Unclear measure of ‘‘stigma and Unclear measure of adherence. Stigma and discrimination
et al. [68] outpatients (61 % women) at discrimination’’ Poor adherence defined measure was associated with
rural medical center in Ido- as \95 % prescribed doses. poor adherence (OR = 23.68;
Ekiti, Nigeria 95 % 1.49–376.80), after
adjusting for demographics and
med usage duration

123
 Table 1 continued
Author Publication Study design and population
year characteristics
123
Peltzer et al. 2010 Prospective study of 519 adults
[77] (74 % female) newly
initiating ART at one of three
public hospitals in Kwazulu-
Natal, South Africa
Peretti-Watel 2006 Cross-sectional study of 2932
et al. [64] adults recruited from 102
hospitals in France
Rao et al. [57] 2012 Cross-sectional study of 720
outpatients from a hospital-
based HIV clinic in Seattle,
WA
Rintamaki 2006 Cross-sectional study of 204
et al. [42] outpatients (80 % male) at
two outpatient infectious
disease clinics in Chicago, IL
and Shreveport, LA
Sayles et al. 2009 Cross-sectional study of 202
[53] adults (56 % black) recruited
from five community
organizations and two HIV
clinics in Los Angeles
Type of Stigma measurement
stigma
Internalized; 7-item version of the AIDS-
Enacted Related Stigma Scale [125],
modified to reflect internalized
stigma (a = .64); 7-item AIDS-
related discrimination scale
(a = .54)
Enacted HIV-related discrimination by
relatives, friends, or sex partners
Combined Four items related to internalized
and enacted stigma from the
Stigma Scale for Chronic Illness
[126]
Combined Three items from the PMAQ [127]
related to disclosure concerns
and internalized stigma
(a = .72). Participants
categorized as high, moderate, or
low stigma concerns
Combined 28-item stigma scale [113].
Participants categorized as high
or low stigma
Adherence measurement
9-item ACTG Adherence
Instrument [99] and 30-day VAS
[112] administered at 6-month
follow-up. For VAS, full
adherence defined as 100 %,
partial adherence C95 %
and \100 %, and non-adherence
as \95 % prescribed doses
Four self-report items assessing
missed doses over past 7 days
and dose timing. Participants
categorized as high, moderate,
and poor adherence
Three items from the ACTG
Adherence Instrument [99], one
item rating ability to take meds
(past 4 weeks), and a VAS (past
month) [112]
Self-report items from PMAQ
[127, 128] assessing missed dose
in past 4 days. Non-adherence
defined as \100 % prescribed
doses
Single item assessing ability to
take meds exactly as prescribed
over past week [129].
Suboptimal adherence defined as
any response other than ‘‘all of
the time’’
Core findings
Internalized stigma was not
associated with the VAS
(OR = 1.11; 95 %
CI = 0.97–1.27) or ACTG
(OR = 0.98; 95 %
CI = 0.88–1.09), after
controlling for alcohol use and
social support. AIDS-related
discrimination was associated
with the VAS (AOR = 0.60;
95 % CI = 0.46–0.78) and
ACTG (AOR = 0.28; 95 %
CI = 0.19–0.41)
Discrimination from sex partners
was associated with poor
(AOR = 1.68; 95 %
CI = 1.00–2.82) and moderate
adherence (AOR = 1.35; 95 %
CI = 1.07–1.70) compared to
high adherence, after controlling
for side effects, alcohol and drug
abuse, and disclosure
Stigma was associated with poor
adherence (b = -0.21,
p \ 0.01). In a structural
equation model, depression
partially mediated the
relationship between stigma and
adherence
High stigma was associated with
greater likelihood of non-
adherence (AOR = 3.3; 95 %
CI = 1.4–8.1), after controlling
for demographics, number of
meds, and site
In bivariate analyses, high stigma
was associated with suboptimal
adherence (OR = 2.45; 95 %
CI = 1.23–4.91). Mental health
mediated the relationship
between stigma and adherence,
after controlling for predisposing
factors, enabling factors, and
AIDS Behav
clinical need characteristics
 Table 1 continued
Author Publication Study design and population Type of Stigma measurement Adherence measurement Core findings
year characteristics stigma
AIDS Behav

Sumari-de 2012 Cross-sectional study of 201
Boer et al. outpatients (56 %
[76] immigrants) at an HIV clinic
in Amsterdam, the
Netherlands
Tilahun et al. 2012 Cross-sectional study of 1,722
[74] adults recruited from a
hospital-based HIV clinic in
Addis Ababa, Ethiopia
Tyer-Viola 2014 Cross-sectional study of 383
et al. [51] women in North America
recruited from infectious
disease clinics and AIDS
service organizations
Vanable et al. 2006 Cross-sectional study of 221
[62] outpatients recruited from an
infectious disease clinic in
central NY state
Waite et al. 2008 Cross-sectional study of 204
[43] outpatients (80 % male) at
two outpatient infectious
disease clinics in Chicago, IL
and Shreveport, LA
Anticipated; Two subscales of the HIV Stigma
enacted Scale [101]: Personalized stigma
(a = .94) and disclosure
concerns (a = .85)
Enacted; HIV Stigma Scale [101]:
internalized; personalized stigma, negative
self-image, concern with public
anticipated;
attitudes, and disclosure
anticipated concerns
Combined 40-item HIV Stigma Scale [101]
Enacted Five items assessing the frequency
of stigma-related experiences
(a = .89)
Combined Three items from the PMAQ [127]
related to disclosure concerns
and internalized stigma.
Participants categorized as high,
moderate, or low stigma
concerns
Pharmacy refill adherence in the
past month. Non-adherence
defined as \100 % adherence
Four items from the Morisky
Medication-Taking Adherence
Scale [110]. Respondents
categorized as ‘‘never missed
meds or ‘‘have ever missed
meds’’
Using the VAS [130], participants
marked percentage of time they
were able to take meds as
prescribed over past 3 and
30 days. Non-adherence defined
as \100 %
Four items adapted from
previously validated measures
[84, 99], which assessed
adherence behaviors over past
week. A summary score was
computed by averaging across
items (a = .80)
Self-report items from PMAQ
[127, 128] assessing missed dose
in past 4 days. Non-adherence
defined as \100 % doses
Anticipated stigma was associated
with non-adherence
(AOR = 1.1; 95 %
CI = 1.01–1.2) but not
personalized stigma (estimates
not given), after adjusting for
demographics, prior virological
failure, and depression
In a logistic regression model,
negative self-image, concern
about public attitudes, and
disclosure concerns were
associated with adherence, after
controlling for demographics,
treatment duration, and
disclosure. Personalized stigma
was not associated with
adherence
Stigma was associated with both
measures of non-adherence in
bivariate analyses. After
adjusting for depression and
healthcare provider engagement,
stigma was not associated with
3- or 30-day adherence
(B = -.02, B = .01)
In a multiple regression model,
stigma was associated with
adherence difficulties
(B = -0.20, p \ 0.01), after
controlling for demographics,
depression, and disclosure
High stigma was associated with
non-adherence (AOR = 3.7;
95 % CI = 1.5–9.1), after
adjusting for demographics,
insurance coverage,
employment, mental health
treatment, and alcohol or drug
treatment

123
 AIDS Behav

adherence (estimates not shown)

ACTG AIDS Clinical Trials Group, AOR adjusted odds ratio, CASE Center for Adherence Support Evaluation, 95 % CI 95 % confidence interval, MSM men who have sex with men, OR odds
with factors such as depression, disclosure, access to care,

1.00–1.95), after controlling for

missed doses in the past 2 days
In bivariate analyses, stigma was
and family functioning remaining as significant predictors.

analyses, perceived external

stigma was associated with
In multiple linear regression
Finally, one investigation by Musumari et al. [59] reported

not associated with non-

(AOR = 1.40; 95 % CI
no univariate association between internalized stigma and
adherence difficulties, as assessed by a composite score of
pharmacy refill and self-reported adherence.

demographics
Core findings

Studies Focusing on Enacted Stigma

Three studies assessed enacted stigma, or past experiences

of discrimination, stereotyping, and/or prejudice from
adherence over past month using
Self-reported missed doses in the

Self-reported missed doses over

past 4 days, adapted from the

others as a result of having HIV. Enacted stigma was

a modified VAS [130]. Non-
adherence defined as \95 %
ACTG [99]. Self-reported

assessed using items developed in previous research

adherence on one or both
Adherence measurement

regarding the frequency of stigma-related experiences [62],

the past 2 and 7 days

as well as single items assessing perceived discrimination

in various social contexts [63, 64]. Findings from these
studies all provided support for an association between
instruments

enacted stigma and poor adherence. In an investigation by

Vanable et al. [62], self-reported adherence emerged as a
significant predictor of negative behavior and mistreatment
at the multivariate level, after controlling for demograph-
worried respondents were about
particular consequences due to

Two 6-item scales adapted from

ics, depression, and disclosure. Additionally, Peretti-Watel

and perceived external stigma
internalized stigma (a = .88)
the HIV Stigma Scale [101]:
HIV status (a = .90) [131]

et al. [64] found that perceived discrimination from sexual

10-item scale assessing how

partners, but not relatives or friends, was associated with

self-reported adherence difficulties at the multivariate
Stigma measurement

level, while Boyer et al. [63] found that perceived dis-

crimination from partner or close family members was
(a = .91)

associated with self-reported adherence difficulties at the

multivariate level. Although Peretti-Watel et al. controlled
ratio, PMAQ Patient Medication Adherence Questionnaire, VAS Visual Analog Scale

for disclosure, neither investigation included mental health

symptoms in multivariate analyses.
Internalized;
Anticipated

anticipated

Studies Focusing on Anticipated Stigma

Type of
stigma

Three studies assessed anticipated stigma, which involves

expectations of discrimination, stereotyping, and/or preju-
Baltimore, MD, Chicago, IL,
homeless or unstably housed

housing service agencies in

urban, faith-based clinic in

dice from others in the future due to one’s HIV status.

Study design and population

Cross-sectional study of 340

Cross-sectional study of 637

adults recruited from local

patients recruited from an

Anticipated stigma was assessed with a 10-item measure

and Los Angeles, CA

regarding how worried respondents were about particular

negative consequences due to their serostatus [65], as well
as single items assessing fear of stigma in various social
characteristics

Tanzania

contexts [66, 67]. Findings from these studies provided

mixed support for an association between anticipated
stigma and adherence. An investigation by Nachega et al.
[66] found a univariate association between fear of stigma
Publication

from a sex partner and adherence difficulties, but did not

conduct multivariate analyses. In Nozaki et al.’s [67]
2010

2009
year

investigation of PLWH in rural Zambia, the association

Table 1 continued

between anticipated stigma (defined as ‘‘fear of stigma

Wolitski et al.

resulting from taking ARVs at home or work’’) and

Watt et al.

adherence disappeared at the multivariate level, where only

Author

[65]

[75]

age, ‘‘ways to remember when to take ARVs,’’ and

‘‘feeling pressured to share ARVs with someone’’ remained

123
AIDS Behav
significant. Finally, Watt et al. [65] found no univariate
association between respondents’ fear of negative conse-
quences due to their serostatus and self-reported adherence.
Studies Where Stigma Measure was Unclear
The approach to assessing stigma was not described in four
studies. In one investigation, Omosanya et al. [68] reported
a significant association between stigma and adherence
difficulties in multivariate analyses, after controlling for
demographics and medication usage duration. Two other
investigations found univariate associations between
stigma and adherence, but did not conduct multivariate
analyses [69, 70]. In contrast, Carlucci et al. [71] did not
find a significant univariate association between stigma and
adherence.
Studies Using Multiple Measures of Stigma
Eight studies assessed multiple domains of stigma and
examined their independent effects in multivariate analy-
ses, although studies varied in how stigma was assessed
and what types of stigma were used. The most frequently
used measure was subscales or items from the HIV Stigma
Scale [72–76], as well as scales or items from the AIDS-
related Stigma Scale [77], Internalized AIDS-related
Stigma Scale [73], or the HIV Felt Stigma Questionnaire
[78]. Findings from these studies were generally supportive
of an association between at least one type of stigma and
adherence difficulties, but the domain of stigma associated
with adherence varied across studies.
Two investigations simultaneously assessed internalized,
anticipated, and enacted stigmas in their analyses [72, 74].
Whereas Tilahun et al. [74] found a significant association
between both internalized and anticipated stigmas and self-
reported adherence in multivariate analyses, Earnshaw et al.
[72] found a marginal association between only internalized
stigma and self-reported adherence difficulties in multi-
variate analyses. Additionally, two investigations that
assessed differences between internalized and enacted
stigmas found contrasting results [73, 77]. Whereas Lyimo
et al. [73] found that internalized stigma was prospectively
associated with self-reported adherence difficulties, Peltzer
et al. [77] found that enacted stigma (measured as ‘‘AIDS-
related discrimination’’) was prospectively associated with
self-reported adherence difficulties. Another investigation
by Wolitski et al. [75] examined differences between
internalized and anticipated stigmas, finding that anticipated
stigma was associated with adherence difficulties in multi-
variate analyses. Finally, an investigation by Sumari et al.
[76] included anticipated and enacted stigmas, but found
that only anticipated stigma was associated with pharmacy
refill adherence in multivariate analyses.
Additional investigations assessed stigma with measures
that deviated from our delineation of internalized, antici-
pated, and enacted stigmas. An investigation by Nyamathi
et al. [79] used measures of internalized stigma, enacted
stigma, vicarious stigma (i.e., hearing stories of enacted
stigma targeting others), and felt stigma (i.e., perception of
stigma in the community). In this investigation, the authors
found that although internalized and vicarious stigma had
univariate associations with adherence, as assessed by
observed pill counts, neither was significantly associated
with adherence in multivariate analyses, after including
depression and adherence support from parents. A second
investigation by Kingori et al. [78] used an 18-item felt
stigma instrument, which included four subscales of
ostracize (i.e., enacted stigma), discrimination (i.e., enacted
stigma), public attitudes (i.e., combined internalized and
anticipated stigmas), and personal life disrupted (i.e.,
feeling like work or home life has been disrupted due to
one’s serostatus). In this investigation, the authors found
that public attitudes and personal life disrupted subscales
were associated with self-reported adherence in multivari-
ate analyses, after controlling for ostracize, discrimination,
and depression.
Summary
First, there is mounting evidence that HIV-related stigma
interferes with medication adherence among PLWH. The
majority of studies using single measures of stigma
(n = 24/29) found an association between increased
stigma and adherence difficulties, while every study
assessing multiple indicators (n = 8/8) found an associ-
ation between at least one type of stigma and nonadher-
ence. This convergence in findings is particularly
noteworthy given that these studies include diverse
patient populations sampled from countries with different
social, economic, and political contexts, each with a dif-
ferent experience of the AIDS epidemic. HIV-related
stigma is influenced by the socio-cultural context in which
it occurs, including variations in the nature of the epi-
demic and the response to the epidemic by policymakers
[80]. Despite this, research has found that there are often
commonalities in what causes stigma, the forms in which
stigma is expressed, and the consequences of stigma [80].
Thus, our findings indicate that there may be common-
alities in how stigma impacts adherence across different
socio-cultural contexts.
Additionally, in a subset of studies (n = 7) in our
review, significant univariate associations between stigma
and adherence were attenuated in multivariate analyses,
suggesting a more complex relationship between stigma
and adherence. Of note, all but one of these multivariate
models included depressive symptoms, which may
123

potentially mediate the pathway between HIV-related
stigma and medication adherence. Thus, while the litera-
ture demonstrates strong support for a link between stigma
and adherence difficulties, many fundamental questions
remain unanswered, including what causal mechanisms
link stigma to adherence difficulties.
Finally, the subset of studies that assessed multiple
domains of stigma simultaneously in multivariate analyses
varied in types of stigma assessed, making it difficult to
provide firm conclusions about unique associations
between different types of stigma and adherence difficul-
ties. However, measures of internalized (n = 3/6) and
anticipated (n = 3/4) stigmas were more consistently
associated with adherence difficulties in multivariate
analyses than enacted stigma measures (n = 1/8), sug-
gesting that they may exert a more proximal influence on
adherence behavior. Future research should strive to assess
all three types of stigma simultaneously, in order to help
clarify these unique associations and whether they vary for
different patient populations.
Proposed Causal Mechanisms of HIV-Related
Stigma and HIV Medication Adherence
Although the majority of studies suggest that stigma con-
tributes to adherence difficulties for PLWH, the mecha-
nisms linking stigma to nonadherence are unknown.
Possible mechanisms were commonly suggested in the
studies reviewed, including enhanced vulnerability to
mental health difficulties, reduction in self-efficacy for pill
taking, and concerns about inadvertent disclosure of HIV
status.
Vulnerability to Mental Health Difficulties
In framing the hypothesis that stigma is linked to adher-
ence, many studies proposed that mental health difficulties
may mediate this association. These studies cite qualitative
research that has found associations between stigma and
depressive symptoms, as well as depressive symptoms and
adherence. PLWH may have internalized negative beliefs
or feelings about having HIV (i.e., internalized stigma)
[72]. Internalized stigma may enhance vulnerability to
mental health difficulties, in particular depressive symp-
toms, which may cause lapses in adherence. Understanding
the specific types of depressive symptoms associated with
stigma may be particularly important, as one study has
found that cognitive symptoms affect adherence more than
vegetative symptoms [81]. Internalized stigma may have a
stronger link to cognitive depressive symptoms, such as
depressed mood, loss of interest, worthlessness, and poor
concentration. In contrast, vegetative depressive symp-
toms, such as fatigue, loss of appetite, sleep disturbance,
123
AIDS Behav
and psychomotor agitation, may overlap with HIV-related
symptoms [82].
Several studies have empirically tested mental health
difficulties as a causal mechanism. Sayles et al. hypothe-
sized that PLWH who are experiencing high levels of
stigma may be more likely to experience adherence diffi-
culties because of increased vulnerability to mental health
difficulties [53]. Mental health difficulties were assessed
using a composite score from the Medical Outcomes Study
Short Form (SF-12), which screens for both anxiety and
depressive symptoms [83]. Results from logistic regression
analyses confirmed that lower mental health status medi-
ated the relationship between stigma and self-reported
adherence difficulties.
Another investigation by Rao et al. also examined
mental health as a mediator between stigma and adherence,
but specifically targeted depressive symptoms, as measured
by the Patient Health Questionnaire (PHQ-9) [57]. The
authors hypothesized that stigma would be associated with
depressive symptoms including fatigue, diminished con-
centration, and feelings of worthlessness, which are all
factors that may interfere with adherence. As hypothesized,
results from SEM confirmed that depressive symptoms
partially mediated the relationship between increased
stigma and worse adherence. In contrast, a more recent
investigation by Kleinman et al. [48] reported that there
was no evidence that depression, as measured by the Major
Depression Inventory, mediated the relationship between
stigma and adherence. This investigation did not find a
significant relationship between stigma, as assessed by the
HIV Stigma Scale and three separate single-item adherence
measures (i.e., Visual Analog Scale, missed doses in last
4 days, last missed dose) [48].
The investigations by Sayles et al. [53] and Rao et al.
[57] are the first to provide evidence that stigma may
enhance vulnerability to mental health difficulties, which in
turn may interfere with self-care related activities such as
adherence. However, neither study controlled for important
covariates, including social support and self-efficacy [84,
85]. Controlling for self-efficacy may be particularly
important, as the perception of increased barriers to
adherence that results from mental illness may be the
proximal determinant of adherence difficulties. The mental
health measures used in both studies are also problematic.
The mental health composite score used by Sayles et al.
[53] represents a global measure of mental health and lacks
specificity in targeting depressive symptoms. Although
Rao [57] specifically targeted depressive symptoms using
the PHQ-9, this too could be improved. Research has
demonstrated that there is considerable overlap between
the vegetative symptom items on depressive inventories
such as the PHQ-9 and HIV-related symptoms, which may
inaccurately represent depressive symptomatology [82].
AIDS Behav
Reduction in Self-Efficacy for Medication Taking
In framing the hypothesis that stigma is linked to adher-
ence, a few studies suggested a reduction in self-efficacy
for medication taking as a causal pathway. These studies
cite previous research supporting the relationship between
self-efficacy and adherence. Self-efficacy is a judgment of
one’s ability to organize and execute given types of
behaviors. Self-efficacious people may be more successful
in performing specific behaviors because they are more
likely to persevere under difficult situations. High levels of
stigma may deflate a PLWH’s self-efficacy in taking
medications, which may cause lapses in adherence [60].
One study has examined the role of self-efficacy as a
causal mechanism between stigma and adherence. The
authors tested a psychosocial model of adherence, which
included self-efficacy, depressive symptoms, and social
support [60]. Self-efficacy was measured using four items
from the Antiretroviral Self-Efficacy Scale, while depres-
sive symptoms were measured using four cognitive
depressive symptom items from the Center for Epidemio-
logic Studies Depression Scale. Although the authors
hypothesized that the relationship between stigma and
adherence would be mediated by both self-efficacy and
depressive symptoms, results from SEM suggested that
only self-efficacy mediated this relationship. This finding
suggests that high levels of stigma may deflate one’s
confidence in ability to take medications, which in turn
may worsen adherence. Unlike other studies [53, 57],
depressive symptoms were not found to mediate the rela-
tionship between stigma and adherence. Instead, the
authors found that participants reporting decreased social
support tended to have more depressive symptoms, which
interfered with adherence.
Concerns About Inadvertent Disclosure of HIV Status
Finally, in framing the hypothesis that stigma is linked to
adherence, many studies suggested concerns about inad-
vertent disclosure of HIV status as a causal mechanism.
These studies cite qualitative research that has found
PLWH report skipping doses when they cannot take pre-
scribed medication without being observed doing so.
PLWH who have experienced discrimination, stereotyping,
or prejudice from others (i.e., enacted stigma), or who
anticipate these experiences (i.e., anticipated stigma), may
fear disclosing their HIV status. The complexity of medi-
cation regimens can interfere with PLWH’s ability to
conceal HIV status because it can require pill taking at
inopportune times and in public settings [47]. Anticipated
or enacted stigma may produce concerns about potentially
revealing one’s HIV status when accessing or consuming
medications. In these situations, PLWH may skip doses
rather than risk a potential ‘‘outing’’ as having HIV [86].
Although this mechanism has been commonly cited within
the literature, none of the studies empirically tested this
causal pathway.
Summary
Together, these studies highlight two possible causal
mechanisms, enhanced vulnerability to mental health dif-
ficulties and reduction in self-efficacy for medication tak-
ing, which may help clarify the relationship between
stigma and adherence difficulties. A third causal mecha-
nism, concerns about inadvertent disclosure of serostatus,
has been proposed but remains untested. These findings
elucidate exciting directions for research, as causal mech-
anisms had previously been untested. Identifying these
pathways will illuminate key variables most relevant for
use in future research studies and subsequent interventions.
However, lack of consistency in the measurement of both
stigma and adherence makes it difficult to generalize and
draw comparisons across these studies. Three of the studies
used combined measures of stigma, while one used a
measure of internalized stigma. Although all four studies
used self-reported measures of medication adherence, the
recall periods and response formats varied.
Review Conclusions
Overall, there is substantial evidence to indicate that stigma
contributes to adherence difficulties among PLWH. This
pervasive finding is particularly convincing given such a
range of variability in both patient populations and stigma
measurement, which included measures combining multi-
ple domains, measures assessing individual domains, and
measures assessing multiple domains simultaneously. A
subset of studies in the present review used multiple indi-
cators and assessed multiple domains simultaneously;
however, those that did suggest there are unique associa-
tions between anticipated and internalized stigmas and
adherence, highlighting an intriguing avenue for future
research. Importantly, four studies tested causal mecha-
nisms linking stigma to adherence difficulties and identi-
fied increased depressive symptoms and reduction in self-
efficacy as possible mechanisms. Another mechanism,
concerns about inadvertent disclosure of serostatus, has
been identified by researchers but remains untested.
Investigating causal mechanisms represents potential for
exciting advancements in this literature, as understanding
and clarifying these pathways can inform both future
research studies and subsequent interventions designed to
improve adherence.
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Methodological Critique and Implications
for Future Research
While the extant literature has begun to document an
association between stigma and adherence difficulties,
issues related to study design and hypotheses, predictor and
outcome measurement, and statistical and analytic con-
siderations are significant concerns. These issues, as well as
recommendations for future research, are discussed in the
succeeding sections.
Study Design and Development of Study Hypotheses
Advancing a Theoretical Framework
Within the existing literature, there are commonalities in
how authors linked stigma to adherence difficulties. Iden-
tifying and clarifying causal mechanisms will be critical in
advancing a stronger theoretical framework for this litera-
ture. Earnshaw and Chaudoir [9] hypothesize that the social
and psychological impact of possessing a stigma can
impact the self through three types of stigma (i.e., inter-
nalized, anticipated, and enacted). Future research should
clarify the unique effects of each type of stigma on
adherence and what implications this has for proposed
causal mechanisms linking each type of stigma to adher-
ence. Incorporating relevant constructs in study design and
empirically testing these mechanisms will help clarify how
different types of stigma may impact adherence.
Operationalization and Assessment of Study
Predictors and Outcomes
HIV-Related Stigma
Variability in the operationalization and assessment of
stigma makes it difficult to generalize and compare find-
ings across studies. Many studies use single measures that
combined different types of stigma, making it difficult to
discern what type of stigma impacts adherence. The few
studies that assessed multiple types of stigma often did not
assess all three types of stigma. Stigma measures also lack
time-sensitive language, often asking participants if they
had ever experienced stigma since the time of diagnosis.
This approach makes it difficult to capture current trends in
the relationship between stigma and adherence, particularly
given that most measures of adherence assess specific
recall periods. Finally, most studies employed aggregate
measures of perceived external stigma, combining antici-
pated or past experiences of discrimination, stereotyping,
and/or prejudice across a range of settings.
The literature would benefit from refining existing measures
and developing more nuanced measures. The measures
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AIDS Behav
developed by Earnshaw and Chaudoir [9] are useful in delin-
eating between the three types of stigma, but the reliability and
validity of these measures need to be evaluated. Efforts to
refine and develop measures should strive for specificity,
making sure to include time-sensitive language that matches
adherence recall periods and differentiates across settings. The
latter may be particularly important, as research has shown that
different types of stigma in different settings may be psycho-
logically more detrimental than others [87]. Differential asso-
ciations for different settings may also operate for adherence
outcomes. One study found that enacted stigma from sex
partners, but not relatives or friends, contributes to adherence
difficulties [64], whereas another study found that enacted
stigma from sex partners or close family members contributes
to adherence difficulties [63]. One hypothesis that could be
examined is that settings where PLWH perceive the greatest
consequences to a potential ‘‘outing’’ are those in which they
are willing to risk nonadherence.
In a critique of stigma measures, Nyblade [11] also
highlighted important concerns that have relevance to the
present review. The author found that few stigma measures
capture both HIV-related stigma and pre-existing stigma, a
construct termed compound or layered stigma [11]. HIV-
related stigma may be layered with pre-existing stigmas,
including the stigma associated with men who have sex
with men, commercial sex workers, and intravenous drug
use. Despite using populations where pre-existing stigma
was presumed to exist, none of the studies attempted to
capture layered stigma. A method for quantitatively mea-
suring layered stigma has been proposed by Reidpath and
Chan [8] and may be useful in assessing this construct. In
addition, Nyblade [11] stresses the need to assess stigma in
a broader range of groups, larger samples, and within more
varied geographical contexts.
Medication Adherence
Clinical indicators such as HIV-1 RNA VL and CD4 lym-
phocyte count are considered the best measures of thera-
peutic response to ART [88]. Given this, it is important to
know whether self-report measures of adherence, which are
commonly used in the literature due to their low cost and
ease of administration, can distinguish between clinically
significant patterns of medication taking behavior. A major
review of the literature on self-report measures of adherence
confirms a significant pattern of associations between self-
reported adherence and VL across a variety of self-reported
measures, administration modalities, and recall periods [89].
The researchers also found an effect of length of self-re-
ported adherence recall period on relation with VL, in that
there was a greater association between longer recall periods
(i.e., [3 days) and VL compared to shorter recall periods
(i.e., \3 days). Together, these results indicate that self-
AIDS Behav
reported adherence strategies may be useful in predicting
successful virologic suppression.
The practicality of self-report makes this method of
assessing adherence likely to remain widely used in clinical
and research settings [89]. However, the absence of stan-
dardized self-report measures has been identified as an
obstacle within this literature [89]. This is consistent with the
present review, in which the self-report measures of adher-
ence suffered from inconsistencies in recall periods and
response formats. Recall periods ranged from 2 to 30 days,
with response formats including count-based recall for shorter
periods (i.e., 2, 4, and 7 days) and estimation recall for longer
periods (i.e., 30 days). Types of items for estimation recall
included frequencies, ratings, and percents. One study has
compared multiple recall periods and response formats for
self-report adherence measures with electronic monitoring
device data [90]. The authors found less overestimation with a
30-day recall period than either 3- or 7-day recall periods. Lu
et al. [90] also found that items that asked patients to rate their
adherence over the past 30 days were more accurate than
frequencies or percents. Longer recall periods may be more
accurate in assessing adherence, as well as represent a more
clinically relevant time interval.
Additionally, research suggests that there are two types
of nonadherence [91–93]. Intentional nonadherence
includes an active decision-making process to disregard
professional advice, whereas unintentional or inadvertent
nonadherence involves a passive process which is less
strongly associated with beliefs and cognitions [92, 94].
Only one study in the present review differentiated
between these two types of nonadherence and found dif-
ferential associations with stigma [55]. Clarifying differ-
ences in intentional and unintentional nonadherence will be
critical in understanding the role of HIV-related stigma as a
barrier to adherence.
Statistical and Analytic Considerations
Reliance on Cross-Sectional Regression Analyses
The majority of studies (n = 33) relied on cross-sectional
regression analyses to characterize the relationship between
stigma and adherence. This reliance on cross-sectional
analyses is particularly problematic when testing causal
mechanisms that may account for the stigma-adherence
relationship, given that an accurate understanding of medi-
ational processes that develop over time require longitudinal
designs. Although most studies of mediation are based on
cross-sectional data due to their low cost and convenience,
cross-sectional approaches to longitudinal mediation can
substantially over- or under-estimate longitudinal effects
[95]. For example, a variable that has found to be a strong
mediator in cross-sectional analyses may not be a mediator
at all in longitudinal analyses [95]. Thus, data analytic
methods that take the passage of time into account, includ-
ing multiple waves of data, will be necessary in future
research to accurately represent true mediational processes
of the stigma-adherence relationship.
Dichotomizing Adherence Data
The majority of studies measured adherence on a continuum
and then categorized the variable at various cut-points pre-
sumably associated with viral suppression, with 95 % or
100 % being the most commonly used cut-points. Although
dichotomizing adherence variables is common practice,
given that these data are often highly skewed, this results in
lost information, reduced power, and an increased proba-
bility of a Type II error [96]. A study comparing continuous,
ordinal, and dichotomous adherence data found that con-
tinuous measures explained the most variance in VL [97].
One solution may be to average measures over multiple
assessment points rather than rely on any single point [97].
This will increase variance in adherence data and provide a
more representative depiction of long-term adherence.
Limited Testing of Mediating Variables
Most studies identified associations between increased
stigma and nonadherence, but few aimed to understand the
causal mechanisms accounting for this association. Studies
that have tested causal mechanisms have identified
increased depressive symptoms [57] and reduction in self-
efficacy for medication taking [60] as two possible expla-
nations. A third causal mechanism, concerns about inad-
vertent disclosure of serostatus, has been hypothesized but
not tested. Future studies should conduct mediational
analyses based on a priori hypotheses to test causal
mechanisms that may account for the relationship between
different types of stigma and nonadherence.
Recommendations for Future Research
To address the methodological and statistical limitations
discussed above, the following recommendations are pro-
vided for future research:
1. Measure multiple domains of HIV-related stigma
simultaneously (i.e., internalized, anticipated, enacted
stigmas), using time-sensitive language that matches
recall periods of adherence and differentiates across a
range of settings for perceived external stigma domains.
Include measures assessing coexisting stigmas in pop-
ulations where they are presumed to exist and account
for these variables in statistical analyses.
123

2. Carefully consider underlying assumptions when
selecting medication adherence measures and attend
to challenges when implementing them. When using
self-report measures, use estimation recall for longer
periods (i.e., 30 days) and differentiate between inten-
tional and nonintentional adherence.
3. Test causal mechanisms between multiple domains of
stigma and adherence in prospective analyses using
more advanced statistical techniques (for e.g., SEM).
Recently identified mechanisms of increased depres-
sive symptoms and reduction in self-efficacy for
medication taking may account for the relationship
between internalized stigma and adherence, whereas
concerns about inadvertent disclosure of serostatus
may mediate the relationship between perceived
external stigmas and adherence.
4. Measure adherence over multiple assessment points to
increase variance and analyze adherence as a contin-
uous variable to avoid lost data.
Implications for Future Intervention Design
Despite recognition of the widespread prevalence of HIV-
related stigma, efforts to eradicate stigma and its damaging
effects have had little success. Few HIV-related interven-
tions specifically target HIV-related stigma, and many of
these existing interventions lack sound theory and
methodology [98]. Therefore, clarifying the mediating
mechanisms linking stigma to adherence difficulties will be
important in designing future interventions to promote
improved adherence. Identifying the most important
determinants of adherence behavior is necessary in order to
select corresponding behavior change techniques. For
instance, associations between internalized stigma,
depressive symptoms, and adherence would require
designing an intervention that includes a cognitive-behav-
ioral component (e.g., challenging internalized beliefs
related to having HIV, enhancing motivation to maintain
optimal health, etc.) On the other hand, associations
between perceived external stigma (i.e., anticipated or
enacted stigma), disclosure concerns, and adherence would
require designing an intervention that includes skill-build-
ing components (e.g., practicing ways to overcome barriers
in social situations, using communication exercises, etc.).
Conclusions
Despite efforts to eradicate HIV-related stigma and its
deleterious effects, stigma continues to exist worldwide
and has far-reaching consequences for PLWH. While the
123
AIDS Behav
existing literature has a number of methodological limita-
tions that can be improved upon in future studies, there is
considerable confirmation that increased stigma contributes
to adherence difficulties in PLWH. Despite this support,
the causal mechanisms for this association remain under-
studied. Studies have tested two mechanisms that may
account for this relationship, vulnerability to mental health
difficulties and reduction in self-efficacy for pill taking.
Another mechanism, concerns about inadvertent disclosure
of HIV status, has not been tested.
Our review suggests that distinct stigma domains may
have unique associations with adherence, which may be
attributable to varied causal mechanisms. One intriguing
direction is to clarify whether mental health difficulties and
reduction in self-efficacy mediate the relationship between
internalized stigma and adherence. Research should also
test whether concerns about inadvertent disclosure of HIV
status through pill taking mediates the relationship between
perceived external stigmas (i.e., anticipated and enacted
stigmas) and adherence. Lastly, it is important for research
to elucidate whether the impact of stigma varies as a
function of how nonadherence is operationalized. It is
hypothesized that all three types of stigma would have
stronger associations with intentional nonadherence.
Overall, review findings confirm the public health sig-
nificance of research examining the impact of stigma on
adherence among PLWH. Future research should strive for
a more uniform approach to assessing stigma to differen-
tiate between the multiple domains of stigma and their
relative impacts. Future studies guided by strong theoreti-
cal frameworks should also include prospective analyses
designed to identify causal mechanisms. With considera-
tion and incorporation of these recommendations, this
research can advance toward a more complete under-
standing of how stigma manifests and operates in a multi-
faceted way. Such advances can contribute to the devel-
opment and implementation of public health interventions
to reduce the negative impact of stigma on the lives of
PLWH.
References
1. AIDS epidemic update. Joint United Nations Programme on HIV/
AIDS, 2013. Available at: http://www.unaids.org/en/media/unaids/
contentassets/documents/epidemiology/2013/gr2013/UNAIDS_
Global_Report_2013_en.pdf. Accessed July 14, 2013.
2. Harrison K, Song R, Zhang X. Life expectancy after HIV
diagnosis based on national HIV surveillance data from 25
states, United States. J Acquir Immune Defic Syndr. 2010;
53(1):124–30.
3. Nosyk B, Min J, Lima VD, Yip B, Hogg RS, Montaner JS. HIV-
1 disease progression during highly active antiretroviral therapy:
an application using population-level data in British Columbia:
1996–2011. J Acquire Immune Defic Syndr. 2013;63(5):653–9.
AIDS Behav
4. Mahajan AP, Sayles JN, Patel VA, et al. Stigma in the HIV/
AIDS epidemic: a review of the literature and recommendations
for the way forward. AIDS. 2008;22(Suppl 2):S67–79.
5. Lowther K, Selman L, Harding R, Higginson IJ. Experience of
persistent psychological symptoms and perceived stigma among
people with HIV on antiretroviral therapy (ART): a systematic
review. Int J Nurs Stud. 2014;51(8):1171–89.
6. Goffman E. Stigma: notes on the management of spoiled iden-
tity. New Jersey: Prentice Hall; 1963.
7. Herek GM, Capitanio JP. AIDS stigma and sexual prejudice.
Am Behav Sci. 1999;42(7):1130–47.
8. Reidpath DD, Chan KY. A method for the quantitative analysis
of the layering of HIV-related stigma. AIDS Care. 2005;17(4):
425–32.
9. Earnshaw VA, Chaudoir SR. From conceptualizing to measur-
ing HIV stigma: a review of HIV stigma mechanism measures.
AIDS Behav. 2009;13(6):1160–77.
10. Link BG. Understanding labeling effects in the area of mental
disorders: an assessment of the effects of expectations of
rejection. Am Sociol Rev. 1987;52(1):96–112.
11. Nyblade LC. Measuring HIV stigma: existing knowledge and
gaps. Psychol Health Med. 2006;11(3):335–45.
12. Endeshaw M, Walson J, Rawlins S, et al. Stigma in Ethiopia:
association with depressive symptoms in people with HIV.
AIDS Care. 2014;26(8):935–9.
13. Hatzenbuehler ML, O’Cleirigh C, Mayer KH, Mimiaga MJ,
Safren SA. Prospective associations between HIV-related
stigma, transmission risk behaviors, and adverse mental health
outcomes in men who have sex with men. Ann Behav Med.
2011;42(2):227–34.
14. Herek GM, Saha S, Burack J. Stigma and psychological distress
in people with HIV/AIDS. Basic Appl Soc Psychol. 2013;
35(1):41–54.
15. Ivanova EL, Hart TA, Wagner AC, Aljassem K, Loutfy MR.
Correlates of anxiety in women living with HIV of reproductive
age. AIDS Behav. 2012;16(8):2181–91.
16. Lee RS, Kochman A, Sikkema KJ. Internalized stigma among
people living with HIV-AIDS. AIDS Behav. 2002;6(4):309–19.
17. Logie C, Gadalla TM. Meta-analysis of health and demographic
correlates of stigma towards people living with HIV. AIDS
Care. 2009;21(6):742–53.
18. Onyebuchi-Iwudibia O, Brown A. HIV and depression in
Eastern Nigeria: the role of HIV-related stigma. AIDS Care.
2014;26(5):653–7.
19. Varas-Diaz N, Serrano-Garcia I, Toro-Alfonso J. AIDS-related
stigma and social interaction: puerto Ricans living with HIV/
AIDS. Qual Health Res. 2005;15(2):169–87.
20. Smith R, Rossetto K, Peterson BL. A meta-analysis of disclo-
sure of one’s HIV-positive status, stigma and social support.
AIDS Care. 2008;20(10):1266–75.
21. Takada S, Weiser SD, Kumbakumba E, et al. The dynamic
relationship between social support and HIV-related stigma in
rural uganda. Ann Behav Med. 2014;48(1):26–37.
22. Corno L, de Walque D. Socioeconomic determinants of
stigmatization and HIV testing in Lesotho. AIDS Care.
2013;25(sup1):S108–13.
23. Fortenberry JD, McFarlane M, Bleakley A, et al. Relationships
of stigma and shame to gonorrhea and HIV screening. Am J
Public Health. 2002;92(3):378–81.
24. Golub SA, Gamarel KE. The impact of anticipated HIV stigma on
delays in HIV testing behaviors: findings from a community-based
sample of men who have sex with men and transgender women in
New York City. AIDS Patient Care STDs. 2013;27(11):621–7.
25. Wolfe WR, Weiser SD, Bangsberg DR, et al. Effects of HIV-
related stigma among an early sample of patients receiving
antiretroviral therapy in Botswana. AIDS Care. 2006;18:931–3.
26. Kelly J, Amirkhanian Y, Yakovlev A, et al. Stigma reduces and
social support increases engagement in medical care among
persons with HIV infection in St. Petersburg, Russia. J Int AIDS
Soc. 2014;17(4Suppl 3):19618.
27. Schuster MA, Collins R, Cunningham WE, et al. Perceived
discrimination in clinical care in a nationally representative
sample of HIV-infected adults receiving health care. J Gen
Intern Med. 2005;20:807–13.
28. Bangsberg DR. Less than 95% adherence to nonnucleoside
reverse-transcriptase inhibitor therapy can lead to viral sup-
pression. Clin Infect Dis. 2006;43(7):939–41.
29. Paterson DL, Swindells S, Mohr J, et al. Adherence to protease
inhibitor therapy and outcomes in patients with HIV infection.
Ann Intern Med. 2000;133(1):21–30.
30. Carrico AW, Riley ED, Johnson MO, et al. Psychiatric risk
factors for HIV disease progression: the role of inconsistent
patterns of antiretroviral therapy utilization. J Acquir Immune
Defic Syndr. 2011;56(2):146–50.
31. Gardner EM, Hullsiek KH, Telzak EE, et al. Antiretroviral
medication adherence and class- specific resistance in a large
prospective clinical trial. AIDS. 2010;24(3):395–403.
32. Harrigan PR, Hogg RS, Dong WW, et al. Predictors of HIV
drug-resistance mutations in a large antiretroviral-naive cohort
initiating triple antiretroviral therapy. J Infect Dis.
2005;191(3):339–47.
33. Rosenbloom DI, Hill AL, Rabi SA, Siliciano RF, Nowak MA.
Antiretroviral dynamics determines HIV evolution and predicts
therapy outcome. Nat Med. 2012;18(9):1378–85.
34. Cambiano V, Lampe F, Rodger A, et al. Use of a prescription-
based measure of antiretroviral therapy adherence to predict
viral rebound in HIV-infected individuals with viral suppression.
HIV Med. 2010;11(3):216–24.
35. Ortego C, Huedo-Medina TB, Llorca J, et al. Adherence to
highly active antiretroviral therapy (HAART): a meta-analysis.
AIDS Behav. 2011;15(7):1381–96.
36. Golin C, Isasi F, Bontempi JB, Eng E. Secret pills: HIV-positive
patients’ experiences taking antiretroviral therapy in North
Carolina. AIDS Educ Prev. 2002;14(4):318–29.
37. Rao D, Kekwaletswe TC, Hosek S, Martinez J, Rodriguez F.
Stigma and social barriers to medication adherence with urban
youth living with HIV. AIDS Care. 2007;19(1):28–33.
38. Mak WS, Poon CM, Pun LK, Cheung S. Meta-analysis of
stigma and mental health. Soc Sci Med. 2007;65(2):245–61.
39. Chesney MA, Smith AW. Critical delays in HIV testing and
care: the potential role of stigma. Am Behav Sci. 1999;42(7):
1162–74.
40. Katz IT, Ryu AE, Onuegbu AG, et al. Impact of HIV-related
stigma on treatment adherence: systematic review and meta-
synthesis. J Int AIDS Soc. 2013;16(3 Suppl2):18640.
41. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement
for reporting systematic reviews and meta-analyses of studies
that evaluate health care interventions: explanation and elabo-
ration. PLoS Med. 2009;6(7):e1000100.
42. Rintamaki LS, Davis TC, Skripkauskas S, Bennett C, Wolf MS.
Social stigma concerns and HIV medication adherence. AIDS
Patient Care STDs. 2006;20(5):359–68.
43. Waite KR, Paasche-Orlow M, Rintamaki LS, Davis TC, Wolf
MS. Literacy, social stigma, and HIV medication adherence.
J Gen Intern Med. 2008;23(9):1367–72.
44. Kekwaletswe CT, Morojele NK. Patterns and predictors of
antiretroviral therapy use among alcohol drinkers at HIV clinics
in Tshwane, South Africa. AIDS Care. 2014;26(sup1):S78–82.
45. Morojele NK, Kekwaletswe CT, Nkosi S. Associations between
alcohol use, other psychosocial factors, structural factors and
antiretroviral therapy (ART) adherence among South African
ART recipients. AIDS Behav. 2014;18(3):519–24.
123

46. Cardarelli R, Weis S, Adams E, et al. General health status and
adherence to antiretroviral therapy. J Int Assoc Phys AIDS Care.
2008;7(3):123–9.
47. Halkitis PN, Perez-Figueroa RE, Carreiro T, Kingdon MJ,
Kupprat SA, Eddy J. Psychosocial burdens negatively impact
HIV antiretroviral adherence in gay, bisexual, and other men
who have sex with men aged 50 and older. AIDS Care.
2014;26(11):1426–34.
48. Kleinman NJ, Manhart LE, Mohanraj R, et al. Antiretroviral
therapy adherence measurement in non-clinical settings in South
India. AIDS Care. 2015;27(2):248–54.
49. Li MJ, Murray JK, Suwanteerangkul J, Wiwatanadate P. Stigma,
social support, and treatment adherence among HIV-positive
patients in Chiang Mai, Thailand. AIDS Educ Prev. 2014;
26(5):471–83.
50. Martinez J, Harper G, Carleton RA, et al. The impact of stigma
on medication adherence among HIV-positive adolescent and
young adult females and the moderating effects of coping and
satisfaction with health care. AIDS Patient Care STDs.
2012;26(2):108–15.
51. Tyer-Viola LA, Corless IB, Webel A, Reid P, Sullivan KM,
Nichols P. Predictors of medication adherence among HIV-
positive women in North America. J Obstet Gynecol Neonatal
Nurs. 2014;43(2):168–78.
52. Levi-Minzi MA, Surratt HL. HIV stigma among substance
abusing people living with HIV/AIDS: implications for HIV
treatment. AIDS Patient Care STDs. 2014;28(8):442–51.
53. Sayles JN, Wong MD, Kinsler JJ, Martins DM, Cunningham
WE. The association of stigma with self-reported access to
medical care and antiretroviral therapy adherence in persons
living with HIV/AIDS. J Gen Intern Med. 2009;24(10):1101–8.
54. Dlamini PS, Wantland D, Makoae LN, et al. HIV stigma and
missed medications in HIV-positive people in five African
countries. AIDS Patient Care STDs. 2009;23(5):377–87.
55. Mo PKH, Mak WWS. Intentionality of medication nonadher-
ence among individuals living with HIV/AIDS in Hong Kong.
AIDS Care. 2009;21(6):785–95.
56. Li X, Huang L, Wang H, Fennie KP, He G, Williams AB.
Stigma mediates the relationship between self-efficacy, medi-
cation adherence, and quality of life among people living with
HIV/AIDS in China. AIDS Patient Care STDs. 2011;25(11):
665–71.
57. Rao D, Feldman BJ, Crane HM, et al. A structural equation
model of HIV-related stigma, depressive symptoms, and medi-
cation adherence. AIDS Behav. 2012;16(3):711–6.
58. Kalichman SC, Grebler T. Stress and poverty predictors of
treatment adherence among people with low-literacy living with
HIV/AIDS. Psychosom Med. 2010;72(8):810–6.
59. Musumari PM, Wouters E, Kayembe PK, et al. Food insecurity
is associated with increased risk of non-adherence to antiretro-
viral therapy among HIV-infected adults in the democratic
Republic of Congo: a cross-sectional study. PLoS One.
2014;9(1):e85327.
60. DiIorio C, McCarty F, DePadilla L, et al. Adherence to
antiretroviral medication regimens: a test of a psychosocial
model. AIDS Behav. 2009;13(1):10–22.
61. Li L, Lee SJ, Wen Y, Lin C, Wan D, Jiraphongsa C.
Antiretroviral therapy adherence among patients living with
HIV/AIDS in Thailand. Nurs Health Sci. 2010;12(2):212–20.
62. Vanable PA, Carey MP, Blair DC, Littlewood RA. Impact of
HIV-related stigma on health behaviors and psychological
adjustment among HIV-positive men and women. AIDS Behav.
2006;10(5):473–82.
63. Boyer S, Clerc I, Bonono CR, Marcellin F, Bilé PC, Ventelou B.
Non-adherence to antiretroviral treatment and unplanned treat-
ment interruption among people living with HIV/AIDS in
123
AIDS Behav
Cameroon: individual and healthcare supply-related factors. Soc
Sci Med. 2011;72(8):1383–92.
64. Peretti-Watel P, Spire B, Pierret J, Lert F, Obadia Y. Manage-
ment of HIV-related stigma and adherence to HAART: evidence
from a large representative sample of outpatients attending
French hospitals (ANRS-EN12-VESPA 2003). AIDS Care.
2006;18(3):254–61.
65. Watt MH, Maman S, Golin CE, et al. Factors associated with
self-reported adherence to antiretroviral therapy in a Tanzanian
setting. AIDS Care. 2010;22(3):381–9.
66. Nachega JB, Stein DM, Lehman DA, et al. Adherence to
antiretroviral therapy in HIV-infected adults in Soweto, South
Africa. AIDS Res Hum Retrov. 2004;20(10):1053–6.
67. Nozaki I, Dube C, Kakimoto K, Yamada N, Simpungwe JB.
Social factors affecting ART adherence in rural settings in
Zambia. AIDS Care. 2011;23(7):831–8.
68. Omosanya OE, Elegbede OT, Agboola SM, Isinkaye AO,
Omopariola OA. Effects of stigmatization/discrimination on
antiretroviral therapy adherence among HIV-infected patients in
a rural tertiary medical center in Nigeria. J Int Assoc Provid
AIDS Care. 2014;13(3):260–3.
69. Achappa B, Madi D, Bhaskaran U, Ramapuram JT, Rao S,
Mahalingam S. Adherence to antiretroviral therapy among
people living with HIV. N Am J Med Sci. 2013;5(3):220.
70. Negash T, Ehlers V. Personal factors influencing patients’
adherence to ART in Addis Ababa, Ethiopia. J Assoc Nurse
AIDS C. 2013;24(6):530–8.
71. Carlucci JG, Kamanga A, Sheneberger R, et al. Predictors of
adherence to antiretroviral therapy in rural Zambia. J Acquir
Immune Defic Syndr. 2008;47(5):615.
72. Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver
MM. HIV stigma mechanisms and well-being among PLWH: a test
of the HIV stigma framework. AIDS Behav. 2013;17(5):1785–95.
73. Lyimo RA, Stutterheim SE, Hospers HJ, de Glee T, van der Ven
A, de Bruin M. Stigma, disclosure, coping, and medication
adherence among people living with HIV/AIDS in northern
Tanzania. AIDS Patient Care STDs. 2014;28(2):98–105.
74. Tilahun HA, Mariam DH, Tsui AO. Effect of perceived stigma
on adherence to highly active antiretroviral therapy and self-
confidence to take medication correctly in Addis Ababa,
Ethiopia. J HIV AIDS Soc Serv. 2012;11(4):346–62.
75. Wolitski RJ, Pals SL, Kidder DP, Courtenay-Quirk C, Holtgrave
DR. The effects of HIV stigma on health, disclosure of HIV
status, and risk behavior of homeless and unstably housed per-
sons living with HIV. AIDS Behav. 2009;13(6):1222–32.
76. Sumari-de Boer IM, Sprangers MAG, Prins JM, Nieuwkerk PT.
HIV stigma and depressive symptoms are related to adherence
and virological response to antiretroviral treatment among
immigrant and indigenous HIV infected patients. AIDS Behav.
2012;16(6):1681–9.
77. Peltzer K, Friend-du Preez N, Ramlagan S, Anderson J.
Antiretroviral treatment adherence among HIV patients in
KwaZulu-Natal, South Africa. BMC Public Health. 2010;10(1):
111.
78. Kingori C, Reece M, Obeng S, et al. Impact of internalized
stigma on HIV prevention behaviors among HIV-infected indi-
viduals seeking HIV care in Kenya. AIDS Patient Care STDs.
2012;26(12):761–8.
79. Nyamathi A, Salem B, Ernst EJ, et al. Correlates of adherence
among rural Indian women living with HIV/AIDS. J HIV AIDS
Soc Serv. 2012;11(4):327–45.
80. Ogden J, Nyblade L. Common at its core: HIV-related stigma
across contexts. 2005.
81. Wagner GJ, Goggin K, Remien RH, et al. A closer look at
depression and its relationship to HIV antiretroviral adherence.
Ann Behav Med. 2011;42(3):352–60.
AIDS Behav
82. Kalichman SC, Sikkema KJ, Somlai A. Assessing persons with
Human Immunodeficiency Virus (HIV) infection using the Beck
Depression Inventory: disease processes and other potential
confounds. J Pers Assess. 1995;64(1):86–100.
83. Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health
survey: construction of scales and preliminary tests of reliability
and validity. Med Care. 1996;34(3):220–33.
84. Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe T.
Patterns, predictors, and barriers to medication adherence among
persons prescribed new treatments for HIV disease. Health
Psychol. 2000;19(2):124–33.
85. Edwards LV. Perceived social support and HIV/AIDS medica-
tion adherence among African American women. Qual Health
Res. 2006;16(5):679–91.
86. Ware NC, Wyatt MA, Tugenberg T. Social relationships,
stigma, and adherence to antiretroviral therapy for HIV/AIDS.
AIDS Care. 2006;18(8):904–10.
87. Stutterheim SE, Pryor JB, Bos AE, Hoogendijk R, Muris P,
Schaalma HP. HIV-related stigma and psychological distress:
the harmful effects of specific stigma manifestations in various
social settings. AIDS. 2009;23(17):2353–7.
88. Bartlett JA. Addressing the challenges of adherence. JAIDS.
2002;29:S2–10.
89. Simoni JM, Kurth AE, Pearson CR, Pantalone DW, Merrill JO,
Frick PA. Self-report measures of antiretroviral therapy adher-
ence: a review with recommendations for HIV research and
clinical management. AIDS Behav. 2006;10(3):227–45.
90. Lu M, Safren SA, Skolnik PR, et al. Optimal recall period and
response task for self-reported HIV medication adherence. AIDS
Behav. 2008;12(1):86–94.
91. Littlewood RA, Vanable PA. The relationship between CAM
use and adherence to antiretroviral therapies among persons
living with HIV. Health Psychol. 2014;33(7):660.
92. Wroe AL. Intentional and unintentional nonadherence: a study
of decision making. J Behav Med. 2002;25(4):355–72.
93. Wroe AL, Thomas MG. Intentional and unintentional nonad-
herence in patients prescribed HAART treatment regimens.
Psychol Health Med. 2003;8(4):453–63.
94. Lehane E, McCarthy G. Intentional and unintentional medica-
tion nonadherence: a comprehensive framework for clinical
research and practice? A discussion paper. Int J Nurs Stud.
2007;44(8):1468–77.
95. Maxwell SE, Cole DA, Mitchell MA. Bias in cross-sectional
analyses of longitudinal mediation: partial and complete medi-
ation under an autoregressive model. Multivar Behav Res.
2011;46(5):816–41.
96. Streiner DL. Breaking up is hard to do: the heartbreak of
dichotomizing continuous data. Can J Psychiatry.
2002;47(3):262–6.
97. Pearson CR, Simoni JM, Hoff P, Kurth AE, Martin DP.
Assessing antiretroviral adherence via electronic drug monitor-
ing and self-report: an examination of key methodological
issues. AIDS Behav. 2007;11(2):161–73.
98. Sengupta S, Banks B, Jonas D, Miles MS, Smith GC. HIV
interventions to reduce HIV/AIDS stigma: a systematic review.
AIDS Behav. 2011;15(6):1075–87.
99. Chesney MA, Ickovics JR, Chambers DB, et al. Self-reported
adherence to antiretroviral medications among participants in
HIV clinical trials: the AACTG adherence instruments. Patient
Care Committee & Adherence Working Group of the Outcomes
Committee of the Adults AIDS Clinical Trials Group (AACTG).
AIDS Care. 2000;12(3):255–66.
100. Carrieri P, Cailleton V, Le Moing V, et al. The dynamic of
adherence to highly active antiretroviral therapy: results from
the French National APROCO cohort. J Acquir Immune Defic
Syndr. 2001;28(3):232–9.
101. Berger BE, Ferrans CE, Lashley FR. Measuring stigma in
people with HIV: psychometric assessment of the HIV stigma
scale. Res Nurs Health. 2001;24(6):518–29.
102. Knobel H, Alonso J, Casado JL, et al. Validation of a simplified
medication adherence questionnaire in a large cohort of HIV-
infected patients: the GEEMA Study. AIDS. 2002;16(4):
605–13.
103. Pequegnat W, Bauman LJ, Bray JH, et al. Measurement of the
role of families in prevention and adaptation to HIV/AIDS.
AIDS Behav. 2001;5(1):1–19.
104. Holzemer WL, Uys LR, Chirwa ML, et al. Validation of the
HIV/AIDS stigma instrument—PLWA (HASI-P). AIDS Care.
2007;19(8):1002–12.
105. Holzemer WL, Bakken S, Portillo CJ, et al. Testing a nurse-
tailored HIV medication adherence intervention. Nurs Res.
2006;55:189–97.
106. Visser MJ, Kershaw T, Makin JD, Forsyth BWC. Development
of parallel scales to measure HIV-related stigma. AIDS Behav.
2008;12(5):759–71.
107. Glass TR, De Geest S, Weber R, et al. Correlates of self-re-
ported nonadherence to antiretroviral therapy in HIV-infected
patients. J Acquir Immune Defic Syndr. 2006;41(3):385–92.
108. Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta
RN, Ginindza T. Measuring AIDS stigmas in people living with
HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS
Care. 2009;21(1):87–93.
109. Reece M. HIV-related mental health care: factors influencing
dropout among low-income, HIV-positive individuals. AIDS
Care. 2003;15(5):707–16.
110. Morisky DE, Green LW, Levine DM. Concurrent and predictive
validity of a self-reported measure of medication adherence.
Med Care. 1986;24(1):67–74.
111. Jeyaseelan L, Kumar S, Mohanraj R, Rebekah G, Rao D,
Manhart LE. Assessing HIV/AIDS stigma in south India: vali-
dation and abridgement of the Berger HIV Stigma Scale. AIDS
Behav. 2013;17(1):434–43.
112. Amico KR, Fisher WA, Cornman DH, et al. Visual Analog
Scale of ART adherence: association with 3-day self-report and
adherence barriers. J Acquir Immune Defic Syndr.
2006;42(4):455–9.
113. Sayles JN, Hays RD, Sarkisian CA, Mahajan AP, Spritzer KL,
Cunningham WE. Development and psychometric assessment of
a multidimensional measure of internalized HIV stigma in a
sample of HIV-positive adults. AIDS Behav. 2008;12(5):
748–58.
114. Herek GM, Capitanio JP. Public reactions to AIDS in the United
States: a second decade of stigma. Am J Public Health.
1993;83(4):574–7.
115. Apinundecha C, Laohasiriwong W, Cameron MP, Lim S. A
community participation intervention to reduce HIV/AIDS
stigma, Nakhon Ratchasima Province, Northeast Thailand.
AIDS Care. 2007;19(9):1157–65.
116. Li X, He G, Wang H, Huang L, Liu L. Development and
evaluation of HIV/AIDS-related stigma and discrimination
scale. Chin J Nurs. 2010;45(6):496–9.
117. Mannheimer SB, Matts J, Telzak E, et al. Quality of life in HIV-
infected individuals receiving antiretroviral therapy related to
adherence. AIDS Care. 2005;17(1):10–22.
118. Wright K, Naar-King S, Lam P, Templin T, Frey M. Stigma
scale revised: reliability and validity of a brief measure of
stigma for HIV ? youth. J Adolesc Health. 2007;40(1):96–8.
119. Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive
validity of a medication adherence measure in an outpatient
setting. J Clin Hypertens. 2008;10(5):348–54.
120. Sakthong P, Chabunthom R, Charoenvisuthiwongs R. Psycho-
metric properties of the Thai version of the 8-item Morisky
123

Medication Adherence Scale in patients with Type 2 diabetes.
Ann Pharmacother. 2009;43(5):950–7.
121. Mak WW, Cheung RY, Law RW, Woo J, Li PC, Chung RW.
Examining attribution model of self-stigma on social support
and psychological well-being among people with HIV?/AIDS.
Soc Sci Med. 2007;64(8):1549–59.
122. Mannheimer SB, Mukherjee R, Hirschhorn LR, et al. The CASE
Adherence Index: a novel method for measuring adherence to
antiretroviral therapy. AIDS Care. 2006;18(7):853–61.
123. Godin G, Gagné C, Naccache H. Validation of a self-reported
questionnaire assessing adherence to antiretroviral medication.
AIDS Patient Care STDs. 2003;17(7):325–32.
124. Steward WT, Herek GM, Ramakrishna J, et al. HIV-related
stigma: adapting a theoretical framework for use in India. Soc
Sci Med. 2008;67(8):1225–35.
125. Kalichman SC, Simbayi LC, Jooste S, et al. Development of a
brief scale to measure AIDS-related stigma in South Africa.
AIDS Behav. 2005;9(2):135–43.
126. Rao D, Choi SW, Victorson D, et al. Measuring stigma across
neurological conditions: the development of the Stigma Scale
for Chronic Illness (SSCI). Qual Life Res. 2009;18(5):585–95.
123
AIDS Behav
127. DeMasi RA, Graham NM, Tolson JM, et al. Correlation between
self-reported adherence to highly active antiretroviral therapy
(HAART) and virologic outcome. Adv Ther. 2001;18(4):
163–73.
128. DeMasi R, Tolson J, Pham S et al. Self-reported adherence to
HAART and correlation with HIV RNA: Initial results with the
Patient Medication Adherence Questionnaire. The Conference
on Retroviruses and Opportunistic Infections; Chicago. 1999.
129. Mannheimer S, Friedland G, Matts J, Child C, Chesney M. The
consistency of adherence to antiretroviral therapy predicts bio-
logic outcomes for human immunodeficiency virus-infected
persons in clinical trials. Clin Infect Dis. 2002;34(8):1115–21.
130. Walsh JC, Mandalia S, Gazzard BG. Responses to a 1 month
self-report on adherence to antiretroviral therapy are consistent
with electronic data and virological treatment outcome. AIDS.
2002;16(2):269–77.
131. Nyblade L, Pande R, Mathur S et al. Disentangling HIV and
AIDS stigma in Ethiopia, Tanzania and Zambia. 2003.