HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention strategy, yet awareness, knowledge, and willingness to use it among people who inject drugs (PWID) remains inadequate despite widespread eligibility. Stigma, particularly HIV-stigmatizing beliefs and attitudes, may be a key barrier to engagement at early stages of the PrEP care continuum. We examine how HIV-stigmatizing beliefs and attitudes affect PrEP awareness, knowledge, and willingness among PWID. We surveyed 262 HIV-negative PWID in Los Angeles and Denver (2021–2023) and used structural equation modeling to examine associations between HIV-stigmatizing beliefs and attitudes (11-item validated scale with α = 0.899 and 1-factor structure) and three early PrEP outcomes: awareness, knowledge, and willingness, while controlling for race/ethnicity, gender, housing status, and conducted sub-analyses on willingness to use long-acting injectable PrEP. HIV-stigmatizing beliefs and attitudes were significantly associated with lower PrEP awareness (β − 0.212, p < 0.001) and less accurate knowledge (β − 0.179, p = 0.006). Accurate knowledge was associated with greater willingness to use PrEP (β 0.175, p = 0.027). Black, Indigenous, and Other Persons of Color (BIPOC) participants reported higher HIV-stigmatizing beliefs and attitudes than non-Hispanic White participants (β 0.196, p = 0.003). Over half (56

Stigma in healthcare settings is a critical barrier to HIV prevention and treatment among people who inject drugs (PWID). While previous tools have measured anticipated stigma, few account for the intersectional and provider-specific experiences of PWID—particularly from syringe service programs (SSPs). We developed and validated the Substance Use Anticipated Provider Stigma Scale (SU-APSS), a multidimensional instrument assessing anticipated stigma from four provider types: healthcare workers, substance use treatment staff, pharmacists, and SSP personnel. Data were drawn from a cross-sectional survey of 264 PWID who were 18 or older, HIV-negative, had injected drugs and used opioids within the past 30 days, and showed visible signs of recent injection. We conducted confirmatory factor analysis (CFA) on responses from 218 participants to evaluate structural validity and used Cronbach’s alpha to assess internal consistency. The CFA supported a four-factor structure with strong model fit indices (CFI = 0.97, RMSEA = 0.09 [0.07, 0.11], SRMR = 0.04). All items significantly loaded onto their respective factors (loadings: 0.62–1.06). Internal consistency was high across all subscales (α = 0.85–0.96) and for the overall scale (α = 0.87). Attribution analysis revealed drug use, physical appearance, and income level as the most common perceived reasons for anticipated stigma. The SU-APSS offers a practical tool for identifying provider-specific stigma, informing stigma-reduction interventions, and evaluating implementation strategies to improve HIV prevention and care engagement among PWID.

Objective:Stigma is a well-recognized barrier to substance use (SU) treatment initiation and retention. It is theorized to operate through three distinct mechanisms: internalized, enacted, and anticipated. The unique associations between these specific stigma mechanisms and key psychosocial factors - such as engagement in reinforcing activities (i.e., behavioral activation), depression, and SU-related problems (e.g., social, financial) - remain unexplored, particularly among historically underserved populations. The current study examined how SU stigma in total and each mechanism is associated with these outcomes among individuals in an urban methadone clinic serving a historically underserved community. Method:This cross-sectional study utilized baseline data from a peer-delivered behavioral intervention trial to examine how SU stigma mechanisms are associated with behavioral activation (BA), depressive symptoms, and SU-related problems among a predominantly low-income sample in methadone treatment (N = 212). Results:Linear regression analyses revealed that overall SU stigma was associated with lower BA, higher depressive symptoms, and greater SU-related problems. In multiple linear regression models controlling for relevant covariates and stigma mechanisms, higher internalized SU stigma remained significantly associated with worse outcomes across all domains. Following multiple-testing correction, associations for anticipated stigma (with lower BA and higher depressive symptoms) and enacted stigma (with greater SU-related problems) were marginally significant. Conclusions:Findings highlight differential associations of stigma mechanisms in psychosocial functioning, and may point to a need to address internalized stigma in SU interventions. Future longitudinal research is needed to assess causal and mechanistic relationships between stigma, SU and psychosocial outcomes to inform targeted intervention development.

Humanitarian crises exacerbate challenges to accessing HIV care. Older people with HIV (OPWH, aged ≥ 50 years) may seek additional support with HIV care, which often requires disclosing their HIV status to healthcare providers, family, or friends. We sought to understand how crises, including COVID-19 and the war with the Russian Federation, have changed OPWH disclosure behaviours over time. We surveyed OPWH in Kyiv, Ukraine, by phone at four-time points: May–June 2020 (Wave 1), January–February 2021 (Wave 2), January–February 2022 (Wave 3) and May–June 2022 (Wave 4). Participants’ responses were compared longitudinally. The primary outcome was new HIV status disclosure, and the independent variables were living conditions (living alone, not living alone) and HIV care support. Other variables analysed were age, gender, comorbidities, social support, depressive and anxiety symptoms, time since diagnosis, and history of addiction. A mixed-effects multivariable logistic regression model was used to assess the relationship between HIV status disclosure and independent variables. Of the 123 participants recruited, 90 OPWH completed the survey across all four-time points, of which 46 (51.1

To examine caregiver age and mutuality as moderators in the relationship between caregiver strain and quality of life (QoL) among caregivers of offspring with intellectual and developmental disabilities (I/DD). A cross-sectional online survey was conducted with 186 parents of offspring with I/DD. Moderation and three-way interaction analyses were performed using Hayes’ PROCESS macro to test caregiver age, mutuality, and their interaction as moderators of the association between caregiver strain and quality of life. The three-way interaction (caregiver strain × mutuality × caregiver age) was statistically significant (p = .01). Higher mutuality buffered the negative impact of caregiver strain on quality of life, but only among younger caregivers. Mutuality serves as an important buffer against the detrimental effects of caregiver strain on quality of life for younger caregivers. However, this buffering effect diminishes as caregivers age. Interventions may benefit from an age-tailored approach, such as enhancing mutuality and relational support for younger caregivers while prioritizing tangible, practical support for older caregivers. These strategies could strengthen the design and delivery of caregiver support programs and policies.

PURPOSE:To develop and validate knowledge scales that span the continuum of substance use disorder (SUD) prevention, treatment, and recovery. Study 1 focused on ensuring the content validity of scale items, and study 2 focused on evaluating the structural, convergent, and known groups validity as well as reliability of the scales. PROCEDURES:Study 1 included n = 15 experts in the SUD field. Study 2 included n = 5355 community members from throughout the U.S. Both studies were conducted online. FINDINGS:The SUD Prevention Knowledge Scale includes 16 items measuring age-related risk factors, other risk factors, and protective factors for SUD. The SUD Knowledge Scale includes 16 items measuring SUD-related characteristics, treatment and recovery, and medications. Supporting content validity, results of study 1 demonstrated that the scales include items with high item-level content validity indexes. Results of study 2 suggested that three-factor models are appropriate for both scales, supporting structural validity, and that the overall scales and subscales have acceptable reliability scores. Both scales and subscales were correlated with indicators of stigma, supporting convergent validity. Participants who were professionals working in the SUD field had the highest scores on the scales, supporting known groups validity. CONCLUSIONS:Results support the validity and reliability of two new measures of SUD-related knowledge. These scales may be appropriate for basic research to characterize levels of SUD knowledge within community settings as well as explore associations between knowledge and SUD-related health behaviors. They may also be useful for evaluating interventions that aim to promote SUD-related knowledge.

OBJECTIVES:The current study aimed to estimate the percentage of US adults who disagree or do not know that addiction is a health condition and explore associations between disagreement that addiction is a health condition with indicators of beliefs about addiction treatment and intentions to support loved ones with addiction. METHODS:A nationally representative sample of US adults was recruited from Gallup's probability-based panel. A total of n=5250 (out of n=12,500 invited) responded to a web-based survey including questions about beliefs about drug or alcohol addiction and treatment. Survey sample weights were applied to correct for unequal selection probability and nonresponse rates, and data were analyzed using descriptive statistics and regression. RESULTS:Close to one-quarter of US adults (23.0%) are estimated to either disagree or not know that addiction is a health condition. Respondents who disagreed or did not know that addiction is a health condition were less likely to believe that addiction is treatable by health care professionals (disagreed: OR=0.33, 95% CI=0.28-0.39; did not know: OR=0.28, 95% CI=0.21-0.36), early intervention for addiction is helpful (disagreed: OR=0.57, 95% CI=0.48-0.66; did not know: OR=0.40, 95% CI=0.31-0.53), or medications are effective treatments for addiction (disagreed: OR=0.47, 95% CI=0.40-0.55; did not know: OR=0.28, 95% CI=0.21-0.37). They were also less likely to indicate that they would help a loved one with addiction (disagreed: OR=0.50, 95% CI=0.40-0.63; did not know: OR=0.65, 95% CI=0.44-0.97). CONCLUSIONS:US adults likely have heterogenous views on addiction, and more research is needed to further understand how US adults conceptualize addiction.

BACKGROUND:People who use drugs (PWUD) often underutilize healthcare services due to multifaceted barriers, especially those transitioning from the criminal legal system. The potential of telemedicine to improve healthcare access for PWUD transitioning from prison to the community remains underexplored. This study investigates the acceptability and feasibility of telemedicine among PWUD and their caregivers. METHODS:We first conducted a cross-sectional survey to explore healthcare utilization patterns and incarceration history. Logistic regression identified factors associated with telemedicine interest. Subsequently, a purposive sample of survey participants (n = 9) provided contextual insights into telemedicine interest. Additionally, key informants-including recently incarcerated PWUD clients (n = 22), community outreach workers (n = 8), and physicians (n = 15)-were interviewed to assess their perspectives. RESULTS:Among 512 PWUD, prior telemedicine experience was low (9.0%), yet interest was substantial (46%). Those who had been incarcerated showed greater interest in telemedicine (50% vs 37%, p = 0.014). Multivariable analysis indicated that telemedicine interest was associated with seeing a doctor in the past year (OR 2.07, p = 0.007), prior telemedicine experience (OR 8.46, p = 0.001), polysubstance use (OR 1.13, p = 0.046), and higher substance-use stigma (OR 1.15, p = 0.023). Interviews revealed that participants valued telemedicine for its convenience, stigma avoidance, decreased labor burden, and enhanced healthcare access. Both PWUD clients and healthcare workers emphasized the importance of involving trusted community NGOs. CONCLUSIONS:Telemedicine offers a promising avenue to enhance healthcare access for marginalized populations, potentially overcoming barriers inherent in traditional healthcare settings. For PWUD transitioning from prison, collaboration with peer workers from NGOs, public clinica staff, and civil society partners may foster trust and tailor telemedicine programs to their specific needs.

Stigma is a well-recognized barrier to accessing emergency food assistance, yet relatively few studies have systematically documented the experiences of pantry clients using a stigma framework. Guided by the Stigma and Food Inequity Framework, this study aimed to examine clients’ experiences of individual-level food insecurity-related stigma and their decisions around disclosing participation in emergency food programs. We conducted 45-minute semi-structured interviews with 18 emergency food program clients in Pennsylvania and Delaware. Discussion guide topics included individual-level stigma (i.e., anticipated, enacted, internalized, stereotype threat), perceived stigma, and disclosure experiences. Demographic and food insecurity (Hunger Vital Sign screener) data were also collected. Data were analyzed using a hybrid inductive and deductive coding approach. Participants experienced multiple forms of stigma while accessing emergency food program assistance, which negatively impacted their well-being and prevented them from returning to certain pantries. Anticipated stigma in the form of embarrassment and nervousness was the mostly commonly reported individual-level stigma manifestation, followed by enacted stigma (e.g., poor treatment by pantry staff). Despite these stigmatizing experiences at food pantries, clients received predominantly positive responses from family and friends upon disclosing their emergency food assistance usage. Interventions such as staff training, anonymous feedback mechanisms for clients and staff, word of mouth recommendations and peer support pantry models, and large-scale marketing efforts may be promising strategies for decreasing individual-level and perceived stigma within emergency food assistance contexts.

With HIV Assisted Partner Notification (APN), individuals with HIV voluntarily name and authorize trained health care workers to inform their at-risk partner of possible exposure to the virus without disclosing the identity of who had named them. Although APN is safe and effective in increasing HIV partner notification and testing, its successful implementation in prison settings to assist incarcerated people with HIV (IPWH) to inform their pre-incarceration partners of possible HIV exposure has yet to be demonstrated. Set in Indonesia where many people with HIV are diagnosed during incarceration, this high-impact study will evaluate the implementation, effectiveness, reach, and sustainability of a prison-based partner notification intervention (Impart) to increase HIV notification and testing among IPWH’s pre-incarceration sex and/or drug partners in the community. A hybrid type 1 effectiveness-implementation study conducted at eight Indonesia jails/prisons will test Impart’s effectiveness to increase HIV partner notification and testing when delivered by non-governmental HIV organizations and their field staff across differing prison contexts. A two-group randomized controlled trial with 216 IPWH recruited as “index participants” will compare Impart (choice of APN or self-tell per partner) with a self-tell only notification condition (Aim 1). Effectiveness outcomes will consist of the proportion of partners within each arm notified of HIV exposure, HIV tested, diagnosed, and beginning antiretroviral therapy if needed within 6-weeks post-randomization. Drawing on the Consolidated Framework for Implementation Research, a mixed method approach will evaluate the multi-level factors (prison characteristics, staff, and implementation processes) required for the model’s successful and sustained implementation when delivered by Impart-trained counseling and notification staff within Indonesia’s prison system (Aim 2). Key factors that contribute to Impart’s reach, fidelity, and sustainment will be identified from stakeholder interviews, prison administrative records, staff logs, and fidelity checks. If proved effective and organizationally sustainable, Impart will provide the first scientifically-tested prison-based APN model to increase HIV testing, diagnosis, and care referral among IPWH’s possibly HIV-exposed sex and/or drug injection partners living in the community. The study’s findings will identify the key elements needed for Impart’s successful implementation and sustainability in Indonesia and potentially other countries with large IPWH populations. This study was registered prospectively at: https://clinicaltrials.gov/study/NCT07103928. Division of AIDS Research, National Institute of Mental Health suzy.pollard@nih.gov

The COVID-19 pandemic may have exacerbated HIV viral suppression disparities between African American/Black and White people living with HIV in the United States. Although COVID-19 disrupted HIV care and caused distress, multilevel resilience resources may have mitigated the impact of COVID-19 distress on HIV viral suppression. We used prospective observational data on 124 African American/Black adults from two clinical cohorts in the Southeastern United States and modified Poisson regression to examine whether an intervention that reduced COVID-19 distress and enhanced multilevel resilience resources would have more effectively improved HIV viral suppression had such a dual intervention been implemented in the real-world during the COVID-19 pandemic. This examination did not yield strong evidence that a real-world dual intervention would have more effectively improved HIV viral suppression on the additive scale during the pandemic among study participants. Larger future studies that minimize systematic sources of bias are needed.

Emerging adults experience the highest rates of mental health problems but the lowest rates of treatment engagement among U.S. adults. Stigma is a well-known barrier to care, undermining outcomes along the mental health treatment cascade from symptom recognition to treatment seeking. In the present study, we examine differences in experiences of stigma among emerging adults based on the presence, recognition, and/or diagnosis of mental health problems. The Voices for Well-Being (Project VOW) is a 12-wave longitudinal study of stigma and mental health in emerging adults (ages 18–21) recruited nationally via snowball and convenience sampling, surveyed quarterly for three years. Using baseline data, we classified participants into four groups: (1) no mental health problem history (n = 608); (2) recognized and diagnosed (n = 2566); (3) recognized and undiagnosed (n = 1417) and (4) unrecognized mental health problem (n = 91). We examined demographic profiles and compared groups across stigma mechanisms (stereotypes, prejudice, discrimination, perceived, anticipated, experienced, and internalized stigma) using ANCOVA models. The Project VOW Cohort is demographically diverse with a high mental health burden; 54.4

HIV continues to disproportionately affect key populations in Malaysia, compared to the general population. Lessons learned from decades of research and programmatic experience suggest that HIV activism can be a driver for change. We pilot-tested a tele-training platform, Project ECHO® for Stigma Reduction (PE-SR), in a randomised controlled trial from July 2022 to March 2023, alongside two comparator groups, i.e., Project ECHO®-Standard (PE-S) and the conventional HIV training program for clinicians, HIV Connect (HC). We randomised 78 primary care physicians and general practitioners across Malaysia into the three study arms (n = 26 each). We evaluated changes in HIV activist identity and commitment, and orientation towards day-to-day HIV activism and structural HIV activism. Repeated measure analysis of covariance (ANCOVA), controlling for age, years of practice, and contact with key populations as covariates, compared changes in HIV activism constructs across time and groups. The randomised controlled trial yielded mixed results. We observed statistically significant changes in HIV activist identity and commitment, as well as changes in orientation towards structural activism in all groups. We also found statistically significant mean differences between PE-S and HC in terms of HIV activist identity and commitment, and between PE-SR and HC in terms of orientation towards structural activism. Results suggest that stigma reduction tools embedded in a tele-training platform had a preliminary impact on HIV activism and could be scaled up and tailored to train clinician-activists. Trial Registration NCT05597787.

Problematic substance use is associated with poor HIV clinical outcomes, including among adolescents and young adults (AYAs) living with HIV. Higher levels of potentially problematic substance use among those diagnosed with HIV during the COVID-19 pandemic may have been mediated by declining levels of social capital and varied depending on an individual’s level of anticipated stigma. We sought to determine whether social capital mediates the relationship between time of HIV diagnosis (pre- versus intra-pandemic) and potentially problematic substance use as a function of anticipated stigma. This moderated mediation analysis utilized baseline data from two demographically similar cohorts of young South Africans ages 18–24 years who tested positive for HIV either before or during the COVID-19 pandemic. The relationships between time of diagnosis in relation to the COVID-19 pandemic, social capital, potentially problematic substance use, and anticipated stigma were analyzed using a series of logistic regression, mediation, and moderated mediation analyses. Compared to their peers diagnosed before the pandemic, young people diagnosed during the COVID-19 pandemic were more likely to screen positive for potentially problematic substance use (OR 3.561; CI 1.827, 6.943; p < 0.001). Social capital was an inconsistent mediator of the relationship between time of diagnosis and potentially problematic substance use, such that lower social support observed among those diagnosed during the COVID-19 pandemic partially suppressed the positive association between pandemic time of diagnosis and potentially problematic substance use (indirect effect = −0.363; CI −0.717, −0.119). There was a significant moderated mediation effect of anticipated stigma (index of moderated mediation = 0.028; CI 0.03, 0.061), indicating that the negative indirect effect of time of diagnosis on potentially problematic substance use weakened at higher levels of anticipated stigma. Diagnosis during the COVID-19 pandemic was associated with a greater likelihood of screening positive for potentially problematic substance use. Although those diagnosed during the pandemic reported lower social capital, social capital was itself associated with potentially problematic substance use. However, this association weakened at high levels of anticipated stigma. These findings may suggest that diagnosis during the pandemic may have exposed those with higher social capital to social networks and norms conducive to substance use, underscoring the need for longitudinal research and interventions addressing the social contexts shaping substance use in this population. Some data from this study emanate from a pilot randomized controlled trial, which was prospectively registered at ClinicalTrials.gov (Identifier: NCT04568460) prior to participant enrollment.

Purpose Young people in South Africa face unique challenges in initiating HIV treatment. There has been limited research on sociobehavioral factors influencing attrition from care among recently diagnosed adolescents and young adults (AYA). Methods We enrolled 100 AYA who recently tested positive for HIV between April 2018 and October 2019 at two community testing sites in Cape Town. We administered a sociobehavioral survey within 2 weeks of diagnosis and 6 months of follow-up and used electronic health records to confirm linkage to care, antiretroviral therapy (ART) initiation, and viral load suppression within 1 year of diagnosis. We used descriptive statistics to explore the general relationships between clinical and sociobehavioral factors. Results Seven participants were excluded from the analysis because they had evidence of ART initiation. Among 93 eligible participants, the majority were not linked to care (n = 82) and over 80% reported food insecurity and HIV diagnosis disclosure concerns. Of those who linked to care (n = 11), 10 initiated ART and 6 achieved viral suppression within 1 year. AYA who initiated ART were more likely to live with a parent/relative (10 of 10 vs. 57 of 83) and were more likely to have disclosed their status to household members (7 of 10 vs. 25 of 83) than noninitiators. Mean baseline scale scores for anticipated and enacted stigma were higher among ART noninitiators compared to ART initiators, with mean differences of 0.4 and 0.5, respectively. Discussion In a sample of recently diagnosed AYA in South Africa, the majority showed no evidence of entering care within a year. All of the participants who initiated ART reported living with a relative and were more likely to disclose their HIV status than noninitiators. Further research is needed to develop effective intervention strategies to address barriers to care for AYA with HIV in South Africa.

ObjectiveLimited research has explored how the attributions of discrimination in later life are related to cognitive functioning.MethodsWe analyzed responses from 12,279 adults ages 65+ in the 2008 to 2018 waves of the Health and Retirement Study. Multilevel mixed models assessed whether cognitive functioning was associated with (1) everyday discrimination (without reference to attribution) and (2) frequency of 11 attributions of discrimination.ResultsDescriptive analyses highlighted variability in the characteristics associated with specific attributions of discrimination. We found that age was the most reported attribution of discrimination, followed by gender. Discrimination was associated with worse cognitive functioning, and frequent reports of certain attributions of discrimination (e.g., disability, sexual orientation) were associated with cognitive functioning.DiscussionThese results suggested that discrimination was harmful for cognitive health and that the perceived reasons for discrimination may have unique and negative implications for cognitive functioning among older adults.

Researchers, interventionists, and clinicians are increasingly recognizing the importance of structural stigma in elevating the risk of mental illnesses (MIs) and substance use disorders (SUDs) and in undermining MI/SUD treatment and recovery. Yet, the pathways through which structural stigma influences MI/SUD-related outcomes remain unclear. In this review, we aim to address this gap by summarizing scholarship on structural MI/SUD stigma and identifying pathways whereby structural stigma affects MI/SUD-related outcomes. We introduce a conceptual framework that describes how structural-level stigma mechanisms influence the MI/SUD treatment cascade via (a) interpersonal- and individual-level stigma mechanisms and (b) mediating processes among people with MI/SUD (i.e., access to resources, psychological responses, behavioral responses, social isolation). We consider intersections between MI/SUD stigma and stigma based on race/ethnicity, gender identity, and sexual orientation. Finally, we discuss the implications of this review for future research, interventions, and clinical practice.