Household Food Insecurity as Mediator of the Association Between Internalized Stigma and Opportunistic Infections

Abstract

Internalized HIV stigma can affect health outcomes, but the mechanism underlying this relationship is poorly understood. We investigated the potential pathways for the association between internalized stigma and opportunistic infections (OIs) among women living with HIV in rural India. We conducted a cross-sectional study involving in-person interviews with 600 participants. We modeled two outcome variables, total number of OIs and fungal dermatoses, which was the most frequently reported OI. Causal mediation analysis was performed to estimate the total effect, direct effect, and indirect effect through mediators while controlling for confounders. Food insecurity was a strong mediator of the association between internalized stigma and the number of OIs (70% of the total effect) and fungal dermatoses (83% of the total effect), while the indirect effect of stigma through adherence was minimal for both outcomes. Household food insecurity may be an important mediator of the impact of HIV-related stigma on opportunistic infections.

Keywords: Adherence; Antiretroviral therapy; Dermatoses; Fungal infections; Nutrition.

Conflict of interest statement

Conflict of Interest: The authors declare that they have no conflict of interest.

Figures

Figure 1. Directed acyclic graph showing mediation pathways leading to opportunistic infections due to internalized stigma

Confounders include: Education, age, years since HIV diagnosis.

Figure 2. Total, direct, and indirect effects of internalized stigma on OIs

A) Effect of internalized stigma on the number of OIs. B) Effect of internalized stigma on fungal dermatoses. C) Percent of total effect on the number of OIs and fungal dermatoses for the direct effect of internalized stigma and the indirect effects through food insecurity and adherence to ART. Models were adjusted for age, education, and years since HIV diagnosis. IRR and OR estimates reflect change per +1 increase in internalized stigma score. OI = opportunistic infections; ART = antiretroviral therapy; OR = odds ratio; IRR = incidence rate ratio; CI = confidence intervals.

Figure 2. Total, direct, and indirect effects of internalized stigma on OIs

A) Effect of internalized stigma on the number of OIs. B) Effect of internalized stigma on fungal dermatoses. C) Percent of total effect on the number of OIs and fungal dermatoses for the direct effect of internalized stigma and the indirect effects through food insecurity and adherence to ART. Models were adjusted for age, education, and years since HIV diagnosis. IRR and OR estimates reflect change per +1 increase in internalized stigma score. OI = opportunistic infections; ART = antiretroviral therapy; OR = odds ratio; IRR = incidence rate ratio; CI = confidence intervals.

Figure 2. Total, direct, and indirect effects of internalized stigma on OIs

A) Effect of internalized stigma on the number of OIs. B) Effect of internalized stigma on fungal dermatoses. C) Percent of total effect on the number of OIs and fungal dermatoses for the direct effect of internalized stigma and the indirect effects through food insecurity and adherence to ART. Models were adjusted for age, education, and years since HIV diagnosis. IRR and OR estimates reflect change per +1 increase in internalized stigma score. OI = opportunistic infections; ART = antiretroviral therapy; OR = odds ratio; IRR = incidence rate ratio; CI = confidence intervals.