Association Between Internalized HIV-Related Stigma and HIV Care Visit Adherence.BACKGROUND
 Internalized HIV-related stigma acts as a barrier to antiretroviral therapy (ART) adherence, but its effects on other HIV care continuum outcomes are unclear.


 Among 196 HIV clinic patients in Birmingham, AL, we assessed internalized HIV-related stigma and depressive symptom severity using validated multi-item scales and assessed ART adherence using a validated single-item measure.  HIV visit adherence (attended out of total scheduled visits) was calculated using data from clinic records.  Using covariate-adjusted regression analysis, we investigated the association between internalized stigma and visit adherence.  Using path analytic methods with bootstrapping, we tested the mediating role of depressive symptoms in the association between internalized stigma and visit adherence and the mediating role of visit adherence in the association between internalized stigma and ART adherence.


 Higher internalized stigma was associated with lower visit adherence (B = -0.04, P = 0.04).  Black (versus white) race and depressive symptoms were other significant predictors within this model.  Mediation analysis yielded no indirect effect through depression in the association between internalized stigma and visit adherence (B = -0.18, SE = 0.11, 95% confidence interval: -0.44 to -0.02) in the whole sample.  Supplemental mediated moderation analyses revealed gender-specific effects.  Additionally, the effect of internalized stigma on suboptimal ART adherence was mediated by lower visit adherence (B = -0.18, SE = 0.11, 95% confidence interval: -0.44 to -0.02).


 CONCLUSIONS
 Results highlight the importance of internalized HIV stigma to multiple and sequential HIV care continuum outcomes.  Also, findings suggest multiple intervention targets, including addressing internalized stigma directly, reducing depressive symptoms, and promoting consistent engagement in care.
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