WJA  Vol.5 No.1 , March 2015
Depression, Internalized HIV Stigma and HIV Disclosure
Purpose: There is extensive evidence regarding the relationship between HIV related stigma and disclosure; however, the influence of depression in this relationship is not well understood, and thus is the focus of our analysis. Methods: Baseline data from a prospective longitudinal cohort of 798 HIV patients starting ART in Kampala, Uganda were examined. A staged-approach regression analysis was used to examine variables associated with HIV disclosure to most people (general disclosure) and disclosure to primary sex partner. Internalized HIV stigma plus demographic and background covariates were first entered into the model; the binary indicator of clinical depression was added on step two, followed by the addition of the interaction of stigma and depression in step three. Separate analyses were conducted for each of the two disclosure outcomes. Results: 39% indicated that they kept their HIV status as a secret from most people, while 19% of respondents with a regular sex partner had not disclosed their HIV status to the partner. In bivariate analysis, respondents who preferred to keep their HIV status as a secret from most people had higher internalized HIV stigma (p < 0.001) and depression (p < 0.01), and were more likely to be clinically depressed (p < 0.01) compared with others in the sample. Similarly, participants who had not disclosed their HIV status to their main sex partner had higher internalized HIV stigma (p < 0.01) and depression (p < 0.05), and were more likely to be clinically depressed (p < 0.01) compared with those who had informed their partner of their HIV status. The regression analysis revealed that internalized HIV stigma was strongly negatively correlated with disclosure to primary partner, while depression was not associated. In the regression analysis for general disclosure, both stigma and depression were negatively correlated with disclosure when the interaction term was included in the model. Further analysis showed that internalized HIV stigma was more strongly associated with general disclosure among participants who were not depressed. Conclusions: Although there was clearly a strong and consistent association between internalized HIV stigma and depression symptoms, the strong association between internalized HIV stigma and general disclosure among respondents who were not depressed indicated that HIV stigma was in itself remained a strong barrier to HIV disclosure. Therefore, interventions to reduce internalized HIV stigma may aid in efforts to decrease secondary transmission of HIV.

Cite this paper
Okello, E. , Wagner, G. , Ghosh-Dastidar, B. , Garnett, J. , Akena, D. , Nakasujja, N. and Musisi, S. (2015) Depression, Internalized HIV Stigma and HIV Disclosure. World Journal of AIDS, 5, 30-40. doi: 10.4236/wja.2015.51004.

[1]   Brouard, P. and Wills, C. (2006) A Closer Look: The Internalization of Stigma Related to HIV. Center for the Study of AIDS/University of Pretoria, and Caroline Wills, POLICY/South Africa.

[2]   Campbell, C., et al. (2005) “I Have an Evil Child at My House”: Stigma and HIV/AIDS Management in a South African Community. American Journal of Public Health, 95, 808-815.

[3]   Kinsler, J.J., et al. (2007) The Effect of Perceived Stigma from a Health Care Provider on Access to Care among a Low-Income HIV-Positive Population. AIDS Patient Care and STDs, 21, 584-592.

[4]   Letteney, S. and Laporte, H. (2004) Deconstructing Stigma: Perceptions of HIV-Seropositive Mothers and Their Disclosure to Children. Social Work in Health Care, 38, 105-123.

[5]   Medley, A., et al. (2004) Rates, Barriers and Outcomes of HIV Serostatus Disclosure among Women in Developing Countries: Implications for Mother-to-Child Transmission Programmes. Bulletin of the World Health Organization, 82, 299-307.

[6]   Ssali, S., et al. (2010) Reasons for Disclosure of HIV Status by People Living with HIV/AIDS and in HIV Care in Uganda: An Exploratory Study. AIDS Patient Care and STDs, 24, 675-681.

[7]   Hays, R., Turner, H. and Coates, T. (1992) Social Support, AIDS-Related Symptoms, and Depression among Gay Men. Journal of Consulting and Clinical Psychology, 60, 463-469.

[8]   Klein, S., Karchner, W. and O’Connell, D. (2002) Interventions to Prevent HIV Related Stigma and Discrimination: Findings and Recommendations for Public Health Practice. Journal of Public Health Management & Practice, 8, 44-53. http://dx.doi.org/10.1097/00124784-200211000-00007

[9]   Makin, J.D., et al. (2008) Factors Affecting Disclosure in South African HIV-Positive Pregnant Women. AIDS Patient Care STDs, 22, 907-916. http://dx.doi.org/10.1089/apc.2007.0194

[10]   Maman, S., et al. (2003) High Rates and Positive Outcomes of HIV-Serostatus Disclosure to Sexual Partners: Reasons for Cautious Optimism from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania. AIDS and Behavior, 7, 373-382.

[11]   Serovich, J. (2001) A Test of Two Disclosure Theories. AIDS Education and Prevention, 13, 355-364.

[12]   Derlega, V., Lovejoy, D. and Winstead, B. (1998) Personal Accounts of Disclosing and Concealing HIV-Positive Test Results: Weighing the Benefits and Risks. In: Derlega, V. and Barbee, A., Eds., HIV Infection and Social Interaction, Sage, Newbury Park, 147-164.

[13]   Antelman, G., Smith Fawzi, M.C., Kaaya, S., Mbwambo, J., Msamanga, G.I., Hunter, D.J. and Fawzi, W.W. (2001) Predictors of HIV-1 Serostatus Disclosure: A Prospective Study among HIV-Infected Pregnant Women in Dar es Salaam, Tanzania. AIDS, 15, 1865-1874.

[14]   Deribe, K., Woldemichael, K., Wondafrash, M., Haile, A. and Amberbir, A. (2008) Disclosure Experience and Associated Factors among HIV Positive Men and Women Clinical Service Users in Southwest Ethiopia. BMC Public Health, 8, 81.

[15]   Farquhar, C., Mbori-Ngacha, D.A., Bosire, R.K., Nduati, R.W., Kreiss, J.K. and John, G.C. (2001) Partner Notification by HIV-1 Seropositive Pregnant Women: Association with Infant Feeding Decisions. AIDS, 15, 815-817.http://dx.doi.org/10.1097/00002030-200104130-00027

[16]   Gari, T., Habte, D. and Markos, E. (2010) HIV Positive Status Disclosure among Women Attending Art Clinic at Hawassa University Referral Hospital, South Ethiopia. East African Journal of Public Health, 7, 87-91.

[17]   Kassaye, K., Lingerh, W. and Dejene, Y. (2005) Associated Factors and Outcomes of Disclosing HIV-Sero Positive Status to Sexual Partners among Women in Mettu and Gore Towns, Illubabor Zone Southwest Ethiopia. The Ethiopian Journal of Health Development, 19, 126-131.

[18]   Lingappa, J.R., Lambdin, B., Bukusi, E.A., Ngure, K., Kavuma, L., Inambao, M., et al. (2008) Regional Differences in Prevalence of HIV-1 Discordance in Africa and Enrollment of HIV-1 Discordant Couples into an HIV-1 Prevention Trial. PLoS ONE, 3, e1411. http://dx.doi.org/10.1371/journal.pone.0001411

[19]   Kiula, E.S., Damian, D.J. and Msuya, S.E. (2013) Predictors of HIV Sero Status Disclosure to Partners among HIV-Positive Pregnant Women in Morogoro, Tanzania. BMC Public Health, 13, 433.

[20]   King, R., Katuntu, D., Lifshay, J., Packel, L., Batamwita, R., Nakayiwa, S., et al. (2008) Processes and Outcomes of HIV Serostatus Disclosure to Sexual Partners among People Living with HIV in Uganda. AIDS and Behavior, 12, 232-243. http://dx.doi.org/10.1007/s10461-007-9307-7

[21]   Stutterheim, S.E., Bos, A.E., Pryor, J.B., Brands, R., Liebregts, M. and Schaalma, H.P. (2011) Psychological and Social Correlates of HIV Status Disclosure: The Significance of Stigma Visibility. AIDS Education and Prevention, 23, 382-392. http://dx.doi.org/10.1521/aeap.2011.23.4.382

[22]   Vu, L., Andrinopoulos, K., Mathews, C., Chopra, M., Kendall, C. and Eisele, T.P. (2012) Disclosure of HIV Status to Sex Partners among HIV-Infected Men and Women in Cape Town, South Africa. AIDS and Behavior, 16, 132-138.http://dx.doi.org/10.1007/s10461-010-9873-y

[23]   Osinde, M.O., Kakaire, O. and Kaye, D.K. (2012) Factors Associated with Disclosure of HIV Serostatus to Sexual Partners of Patients Receiving HIV Care in Kabale, Uganda. International Federation of Gynecology and Obstetrics, 118, 61-64.

[24]   Niccolai, L.M., Dorst, D., Myers, L. and Kissinger, P.J. (1999) Disclosure of HIV Status to Sexual Partners: Predictors and Temporal Patterns. Sexually Transmitted Diseases, 26, 281-285.

[25]   Marks, G. and Crepaz, N. (2001) HIV-Positive Men’s Sexual Practices in the Context of Self-Disclosure of HIV Status. Journal of Acquired Immune Deficiency Syndromes, 27, 79-85.

[26]   Mansergh, G., Marks, G. and Simoni, J.M. (1995) Self-Disclosure of HIV Infection among Men Who Vary in Time since Seropositive Diagnosis and Symptomatic. AIDS, 9, 639-644.

[27]   Niccolai, L.M., King, E., D’Entremont, D. and Pritchett, E.N. (2006) Disclosure of HIV Serostatus to Sex Partners: A New Approach to Measurement. Sexually Transmitted Diseases, 33, 102-105.

[28]   Misovich, S.J., Fisher, J.D. and Fisher, W.A. (1997) Close Relationships and Elevated HIV Risk Behavior: Evidence and Possible Underlying Psychological Processes. Review of General Psychology, 1, 72-107.http://dx.doi.org/10.1037/1089-2680.1.1.72

[29]   Degefa, A., Sanders, E.J., Mekonnen, Y., Messele, T., Wolday, D., Dorigo-Zetsma, W., et al. (2003) Knowledge and Attitudes towards Antiretroviral Therapy among Factory Workers Participating in a Cohort on HIV and AIDS, Addis Ababa, Ethiopia. Ethiopian Medical Journal, 41, 75-87.

[30]   Steward, W.T., Chandy, S., Singh, G., Panicker, S.T., Osmand, T.A., Heylen, E. and Ekstrand, M.L. (2011) Depression Is Not an Inevitable Outcome of Disclosure Avoidance: HIV Stigma and Mental Health in a Cohort of HIV Infected Individuals from Southern India. Psychology Health and Medicine, 16, 74-85.http://dx.doi.org/10.1080/13548506.2010.521568

[31]   Kroenke, K., Spitzer, R. and Williams, J. (2001) The PHQ-9: Validity of a Brief Depression Severity Measure. Journal of General Internal Medicine, 16, 606-613. http://dx.doi.org/10.1046/j.1525-1497.2001.016009606.x

[32]   Monahan, P.O., Shacham, E., Reece, M., Kroenke, K., Ong’or, W.O., Omollo, O., et al. (2007) Validity/Reliability of PHQ-9 and PHQ-2 Depression Scales among Adults Living with HIV/AIDS in Western Kenya. Journal of General Internal Medicine, 24, 189-197.

[33]   Kalichman, S.C., Simbayi, L.C., Jooste, S., Toefy, Y., Cain, D., Cherry, C. and Kagee, A. (2005) Development of a Brief Scale to Measure AIDS-Related Stigma in South Africa. AIDS & Behavior, 9, 135-143.http://dx.doi.org/10.1007/s10461-005-3895-x

[34]   Olley, B., Seedat, S. and Stein, D. (2004) Self-Disclosure of HIV Serostatus in Recently Diagnosed Patients with HIV in South Africa. African Journal of Reproductive Health, 8, 71-76.

[35]   Gaillard, P., Melis, R., Mwanyumba, F., Claeys, P., Muigai, E., Mandaliya, K., et al. (2002) Vulnerability of Women in an African Setting: Lessons for Mother to Child HIV Transmission Programmes. AIDS, 16, 937-939.http://dx.doi.org/10.1097/00002030-200204120-00019

[36]   Kilewo, C., Massawe, A., Lyamuya, E., Semali, I., Kalokola, F., Urassa, E., et al. (2001) HIV Counseling and Testing of Pregnant Women in Sub-Saharan Africa: Experiences from a Study on Prevention of Mother-to-Child HIV-1 Transmission in Dar es Salaam, Tanzania. Journal of Acquired Immune Deficiency Syndromes, 28, 458-462.http://dx.doi.org/10.1097/00042560-200112150-00009

[37]   Brou, H., Djohan, G., Becquet, R., Allou, G., Ekouevi, D.K., Viho, I., et al. (2010) When Do HIV-Infected Women Disclose Their HIV Status to Their Male Partner and Why? A Study in a PMTCT Programme, Abidjan. PLoS Medicine, 4, e342.

[38]   Gari, T., Habte, D. and Markos, E. (2010) HIV Positive Status Disclosure among Women Attending Art Clinic at Hawassa University Referral Hospital, South Ethiopia. East African Journal of Public Health, 7, 87-91.

[39]   Chaudoir, S., Fisher, J. and Simoni, J. (2011) The Disclosure Process Model: A Review and Application of the Disclosure Processes Model. Social Science & Medicine, 72, 1618-1629.

[40]   Earnshaw, V.A. and Chaudoir, S.R. (2009) From Conceptualizing to Measuring HIV Stigma: A Review of HIV Stigma Mechanism Measures. AIDS and Behavior, 13, 1160-1177.

[41]   Lee, R.S., Kochman, A. and Sikkema, K.J. (2002) Internalized Stigma among People Living with HIV-AIDS. AIDS and Behavior, 6, 309-319. http://dx.doi.org/10.1023/A:1021144511957

[42]   Derlega, V.J., Winstead, B.A., Greene, K., Serovich, J. and Elwood, W.N. (2002) Perceived HIV-Related Stigma and HIV Disclosure to Relationship Partners after Finding out about the Seropositive Diagnosis. Journal of Health Psychology, 7, 415-432.

[43]   Clark, H.J., Lindner, G., Armistead, L. and Austin, B.J. (2003) Stigma, Disclosure, and Psychological Functioning among HIV-Infected and Non-Infected African-American Women. Women Health, 38, 57-71.http://dx.doi.org/10.1300/J013v38n04_04

[44]   Ostrom Delaney, R.A., Serovich, J. and Lim, J. (2009) Psychological Differences between HIV-Positive Mothers Who Disclose to All, Some, or None of Their Biological Children. Journal of Marital and Family Therapy, 35, 175-180.http://dx.doi.org/10.1111/j.1752-0606.2009.00114.x

[45]   Armistead, L., Tannenbaum, L., Forehand, R., Morse, E. and Morse, P. (2001) Disclosing HIV Status: Are Mothers Telling Their Children? Journal of Pediatric Psychology, 26, 11-20.

[46]   Emlet, C.A. (2007) Experiences of Stigma in Older Adults Living with HIV/AIDS: A Mixed-Methods Analysis. AIDS Patient Care and STDs, 21, 740-752. http://dx.doi.org/10.1089/apc.2007.0010

[47]   O’Brien, M.E., Richardson-Alston, G., Ayoub, M., Magnus, M., Peterman, T.A. and Kissinger, P. (2003) Prevalence and Correlates of HIV Serostatus Disclosure. Sexually Transmitted Disease, 30, 731-735.

[48]   Farquhar, C., Mbori-Ngacha, D.A., Bosire, R.K., Nduati, R.W., Kreiss, J.K. and John, G.C. (2001) Partner Notification by HIV-1 Seropositive Pregnant Women: Association with Infant Feeding Decisions. AIDS, 15, 815-817.http://dx.doi.org/10.1097/00002030-200104130-00027

[49]   Nguyen, T. and Whetten, K. (2003) Is Anybody Out There? Integrating HIV Services in Rural Regions. Public Health Reports, 118, 3-9. http://dx.doi.org/10.1093/phr/118.1.3

[50]   Mohammed, H. and Kissinger, P. (2006) Disclosure of HIV Serostatus to Sex Partners in Rural Louisiana. AIDS Care, 18, S62-S69. http://dx.doi.org/10.1080/09540120600839371

[51]   Gonzalez, A., Miller, C.T., Solomon, S.E., Bunn, J.Y. and Cassidy, D.G. (2008) Size Matters: Community Size, HIV Stigma, & Gender Differences. AIDS and Behavior, 13, 1205-1212.