Health professionals should address the internalized stigma of this population to reduce the risks and harms associated with substance use and improve their commitment to HIV care
The internalized stigma experienced by gay men, bisexual men and other men who have sex with men (GBHSH) with HIV, especially around drug and / or substance use, would significantly hinder self-care and link with care for the patient. HIV in this population. A qualitative study, the results of which have been published in the journal Social Science & Medicine, has revealed that the participants experienced intersectional self-stigma as a consequence of different axes of inequality that interacted simultaneously, including, in addition, drug use , one's own HIV status, sexual orientation, ethnic origin, effeminate behavior, poverty or housing instability.
According to the US Centers for Disease Control and Prevention (CDC), in 2018, only 65% of GBHSH men with HIV in the North American country systematically attended clinics of HIV and only 57% achieved viral suppression. Evidence reveals that GBHSH men who use drugs and / or substances, especially stimulants, often have poorer adherence to antiretroviral treatment, poorer HIV self-care, and have significantly more irregular access to HIV care services. The negative impact that stigma has on health is well documented, as is the impact of internalizing these negative messages, self-stigma. Previous research shows that self-stigma associated with HIV is a barrier to medical care, and that self-stigma associated with sexual orientation and / or drug use also presents barriers to HIV care.
In order to shed more light on this issue, a team of researchers from Massachusetts General Hospital (USA) carried out a qualitative study, through in-depth semi-structured interviews, with the aim of trying to better understand internalized stigma as a barrier to HIV care. This is the first study to examine the intersection and impact of multiple internalized stigmas on GBHSH men's behavior in relation to self-care and HIV care.
Participants were selected in the city of Boston (Massachusetts), through publicity and dissemination in various community sites and online through dating sites, contacts and social networks. To be included in the study, participants had to have HIV, have used substances and / or drugs (including alcohol) in the previous three months, be GBHSH male, and have insufficient involvement with HIV care. The latter was defined as having a detectable viral load, declaring adherence to antiretroviral therapy less than 90%, or missing two or more appointments in HIV care services in the previous year without rescheduling them.
33 men were included in the study, with a mean age of 51 years. Participants had been living with HIV for an average of 19 years, with 60% being black and 36% white. 36% of the men indicated that they had secondary or lower education, while 46% declared that they had completed some type of university study; 5% had a higher degree. Three-quarters of the participants earned $ 20,000 or less a year.
More than half (58%) of the participants identified as gay men, 27% as bisexual and 15% identified as "other", which included heterosexual men. Most used multiple drugs and / or substances. The use of stimulants was high (79%), as was the use of tobacco (76%), cannabis (67%), "club" drugs -cocaine, ketamine, ecstasy, methamphetamine, GHB or poppers- (40% ) and only alcohol (18%). Most participants also reported using multiple substances, such as alcohol with stimulants (36%), alcohol, stimulants, and sedatives (15%), and alcohol, stimulants, opioids, and sedatives (12%).
Most participants reported some form of internalized stigma affecting their HIV self-care, including self-stigma related to HIV, sexual orientation, race, being effeminate, poverty and gender. situation of the house where they lived.
Almost all participants reported experiencing internalized stigma around substance and / or drug use, and about half spoke explicitly about the intersection between their identities and stigmas. On the other hand, the participants stressed that the aspects associated with their identities were interrelated and could not be experienced in a singular way. The multiple stigmas accentuated each other and affected the way men were judged by society.
Many participants perceived stigma from others and spoke of rejection and lack of belonging from their families and communities. This widespread stigma led to feelings of shame and internalized stigma. Some men explicitly spoke of being stigmatized and marginalized within the communities to which they belonged, such as the gay or HIV community, due to personal characteristics such as being effeminate or not having stable housing. Participants who were religious, particularly black men, noted that stigma was exacerbated within the religious community. However, although almost all black participants described racial discrimination as a challenge, being part of the black community and the black church was described as a source of strength and belonging.
Few participants explicitly linked self-stigma around HIV status or sexual orientation to substance use. However, the men in the study described experiencing established stigma and discrimination in relation to multiple aspects of their identity, and this led to self-judgment and shame. This internalized stigma prolonged and worsened substance use. Almost all reported that internalized stigma around drug use contributed to drug use more than any other stigma. It was described as a cycle: using drugs to feel bad, then feeling bad about using drugs. In this cycle, the use of substances to alleviate negative emotions led to more negative emotions and increased use. This cycle often starts a cascade that leads to disengagement from HIV care, isolation, and increased internalized stigma.
Most of the participants indicated that self-stigma around substance use and substance use itself affected their behavior in relation to self-care, adherence to antiretroviral treatment, and involvement with HIV care services.
In conclusion, the researchers underscore the need for clinicians to consider and address intersecting internalized stigmas, particularly internalized stigma related to substance use, both to reduce substance use and to improve HIV self-care among men. GBHSH who use drugs and are not optimally engaged in HIV care. On the other hand, the study provides evidence that can be used in future research and interventions.
Source: Aidsmap / Own elaboration (gTt-VIH).
References: Batchelder, A et al. Intersecting internalized stigmas and HIV self-care among men who have sex with men and who use substances. Social Science & Medicine, 275, 2021. doi: 10.1016/j.socscimed.2021.113824