In the seminal conceptual work by Goffman (1963), stigma was defined as "an attribute that links a person to an undesirable stereotype, leading other people to reduce the bearer from a whole and usual person to a tainted, discounted one" (p. 3). The term "stigma" also refers to "the process of othering, blaming and shaming" (Deacon, 2006, p. 418). In short, HIV-related stigma reflects societal attitudes at large and the process of shaping and influencing the characteristics of a person being offensive against social and cultural mores and values (Chambers et al., 2015). Negative depictions of people living with HIV (PLWH) in mass media such as portraying them as "drug addicts," "sex workers," and individuals who are seen as irresponsible with the full knowledge of risk have played a significant role in the stigmatization process of HIV/AIDS (Davtyan et al., 2017; Ho & Holloway, 2015).

HIV-related stigma is associated with a variety of health-related outcomes in PLWH (Kay et al., 2018; Reinius et al., 2018; Rueda et al., 2016), quality of life (Fuster-Ruizdeapodaca et al., 2014; Holzemer et al., 2009; Slater et al., 2015), and access to health care and social services (de Villiers et al., 2020; Relf et al., 2019). For example, Relf et al. (2019) demonstrated that women living with HIV experience external negative perceptions directed by people living without HIV toward PLWH. This experience subsequently forged health care distrust and internalized stigma in the form of depressive symptoms (Relf et al., 2019). Despite the geographical, cultural, and social differences among PLWH in the United States, parallel challenges and experiences were found. PLWH in Louisiana identified depression (68%) and anxiety (59%) as the two top challenges to everyday living because of actual and perceived stigma and discrimination (Moore, 2017). Similar percentages of PLWH in Michigan (Arnold et al., 2016) and New Jersey (Bagchi & Peavy, 2018) also endorsed the two mental health symptoms as their top challenges. A meta-analysis of 40 studies revealed a moderate, significant relationship between HIV-related stigma and depressive symptoms and a weak but significant relationship between HIV-related stigma and anxiety symptoms (Rueda et al., 2016).

As stated above, numerous studies found a significant relationship between HIV-related stigma and mental health; however, there is a lack of clarity in the definition of HIV-related sigma that impedes studies on its relationship with mental health. For example, "the term perceived stigma is sometimes used to refer to experienced stigma or internalized stigma" (Fox et al., 2018, p. 4). Zeng et al. (2018) defined perceived stigma as awareness of discriminatory and prejudicial attitudes from other people in the society and internalized stigma as negative self-images resulting from internalizing others' negative views of HIV/AIDS in the society. There is an urgent need to examine the role of HIV-related stigma in various mental health conditions, including depression and anxiety. Furthermore, researchers should clearly define the concept of HIV-related stigma and assess the relationships separately for the perceived and internalized HIV-related stigmas.

Recent studies on PLWH emphasize the importance of adopting an intersectional framework to best explain how living with multiple socially generated devaluing experiences affects the health and quality of life of PLWH (Chambers et al., 2015; Earnshaw et al., 2015; Sangaramoorthy et al., 2017; Wardell et al., 2018). "Intersectional stigma" is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group and to address their joint or intersecting effects on health and well-being (Turan et al., 2019). Turan et al. categorized three forms of stigma using Goffman's general categorization of stigma process, namely (a) physical health conditions, Goffman's "abominations of the body" (e.g., HIV, mental health issues, and epilepsy); (b) affiliations with marginalized groups, Goffman's "tribal" forms of stigma (e.g., racial or ethnic identity, gender, and sexual orientation); and (c) factors attributed to one's [DOUBLE HIGH-REVERSED-9 QUOTATION MARK]moral" character or behaviors, Goffman's "blemishes of individual character" (e.g., smoking, alcohol use, substance use issues, and sex work). Turan et al. (2019) asserted that an intersectional perspective is vital to understanding the experiences and consequences of living with multiple stigmatized identities and that only then will health care providers, public health officials, and advocates be able to design health care interventions.

There is emerging evidence supporting the intersectionality of multiple forms of stigma in PLWH. For example, Earnshaw et al. (2015) reported a moderating effect of substance use stigma with HIV-related stigma on depressive symptoms. PLWH who internalized HIV stigma had greater depressive symptoms only when they also internalized substance use stigma. Additionally, a significant interaction effect of HIV-related stigma with gender and sexual minority stigma on depressive and anxiety symptoms was also found by Yang et al. (2020). However, no known studies have ever examined the intersectionality of HIV-related stigma and tobacco smoking stigma and their interaction effect on depressive and anxiety symptoms. HIV-related stigma increases the odds of smoking among PLWH (Gamarel et al., 2020; Zhang et al., 2018). Although tobacco is a legal substance, smoking behavior is increasingly stigmatizing as people become aware of the detrimental effects of smoking and exposure to secondhand smoke (Brown-Johnson & Popova, 2016; Stuber et al., 2009). A systematic review of studies on tobacco smoking indicated that awareness of smoking stigma is virtually universal (Evans-Polce et al., 2015). In the United States, the prevalence of smoking among women living with HIV is as high as among men living with HIV and nearly four times (40% vs. 12%) that of the general female population (Mdodo et al., 2015; Pacek et al., 2014; Pool et al., 2016). The burden of non-AIDS-related diseases, especially the burden of non-AIDS-defining cancers, has increased three-fold in PLWH over the past decade, and smoking is the major reason for the increase (Reddy et al., 2017; Sigel et al., 2017).

Although findings are mixed in the literature, women are more susceptible to and affected by HIV-related stigma than their male counterparts, receiving negative references and stereotyping as "diseased" and "prostitutes" (Paudel & Baral, 2015). Likewise, Ha et al. (2019) found that women, on average, endorsed more perceived shame, blame, isolation, feelings of inequity, and perceived community stigma toward PLWH than men. As part of their social functions, women are traditionally expected to accept full responsibility for household chores and take care of their husbands and the rest of the family (Asiedu & Myers-Bowman, 2014). People tend to believe that women who fulfill this important social function have no time to play, and only those who have engaged in "play" are getting infected with HIV (Asiedu & Myers-Bowman, 2014). The high rates of depression and anxiety reported by women living with HIV (Aljassem et al., 2016; Colbert et al., 2010; Gebremichael et al., 2018; Prasithsirikul et al., 2017; Sangaramoorthy et al., 2017) may indicate the internalization of pervasive HIV-related stigma toward women in the community.

The purpose of this study was to examine whether the relationships between HIV-related stigma, namely, perceived and internalized HIV-related stigma, and depressive and anxiety symptoms are moderated or changed by tobacco smoking stigma among women living with HIV. Findings could provide a better understanding of how HIV-related stigma interacts with tobacco smoking stigma and how the interaction was related to depressive and anxiety symptoms. We hypothesized that tobacco smoking stigma would worsen the impact of HIV-related stigma on depressive and anxiety symptoms among women living with HIV who were daily smokers.

Method

This study is a secondary analysis of baseline data obtained from two smoking cessation studies that were conducted with women living with HIV. The first study (Kim et al., 2018) was conducted between March 2016 and December 2017, and participants were recruited from Massachusetts and New York City. The study compared the preliminary efficacy of video-call smoking cessation counseling (an HIV-tailored intervention) with traditional telephone-call counseling (an attention-control condition). Irrespective of intervention condition, all participants also received nicotine replacement therapy. The second study (Kim et al., 2020) was conducted between September 2017 and December 2018, and participants were recruited from 13 states in the United States. The study compared the preliminary efficacy of a storytelling smoking cessation film with a storytelling attention-control film. All participants in this study received a video-call smoking cessation counseling and nicotine replacement therapy. Both studies were approved by the institutional review board of the University of Massachusetts Boston (#2016059 and #2017147), and all participants signed an informed consent form before enrollment into the respective study. The studies were also registered on http://Clinicaltrial.gov (NCT02898597 and NCT03289676).

Participants

Eligibility criteria for both studies were identical and included women who (a) were 18 years of age or older; (b) were able to speak English; (c) self-reported smoking daily at a minimum of five cigarettes per day; (d) were able to provide a supporting document of HIV seropositivity (i.e., a laboratory test result and a doctor's note); and (e) were accessible through a video-call app such as FaceTime, Skype, Messenger, etc. (Kim et al., 2018, 2020). Exclusion criteria were as follows: (a) pregnancy or lactation, (b) active skin disease or severe alcohol use problem with a score of 26 or higher on the Alcohol Use Disorders Identification Test (Babor et al., 2001), (c) use of any illegal substances except for marijuana, or (d) active suicidal ideation or a history of serious mental illness such as psychotic or bipolar disorder (Kim et al., 2018, 2020). Due to the high prevalence of psychiatric comorbidity among PLWH (De Francesco et al., 2018; Hutton et al., 2020), we did not exclude individuals who reported a history of depressive and anxiety disorders. On the same note, we did not use any cutoff score of depression and anxiety symptoms to determine eligibility.

Procedures

Participants in the first study (Kim et al., 2018) were recruited using personal networks of health care providers in HIV clinics. Participants in the second study (Kim et al., 2020) were recruited via online advertisements and snowball sampling. Callers were first screened for eligibility via telephone interview, and HIV seropositivity was confirmed by asking them to send a copy of the most recent blood work showing CD4⁺ T-cell count and viral load. Participants in the first study (Kim et al., 2018) received an envelope enclosed with a cover letter, informed consent form, baseline research questionnaires, and a self-addressed stamped envelope for return mail. However, a mail survey yielded a large number of questionnaires with missing answers, and most of those questionnaires needed to be completed by a subsequent telephone interview. As a result, the study protocol was amended and went through an institutional review board review. Participants in the second study (Kim et al., 2020) received a copy of informed consent form via text message or e-mail. They were given time to ask questions about the study and then signed the consent form via text message or e-mail. In this study, data collection was primarily done via telephone interviews. Participants in both studies were randomized at a ratio of 1:1 to either the treatment or the control arm based on a computer-generated random number (Kim et al., 2018, 2020). The present study used baseline data only, and additional detail describing participant flow, smoking cessation interventions, and cessation outcomes of the two parent studies have been reported elsewhere (Kim et al., 2018, 2020).

Measures

Baseline assessments included demographic information, HIV characteristics, and smoking-related data (Kim et al., 2018, 2020). Demographic information comprised race and ethnicity, age, marital status, the highest grade earned, and employment status. HIV characteristics included time since HIV diagnosis, CD4⁺ T-cell counts, and viral loads. For smoking-related data, age at which participants started smoking regularly (smoking onset) and the number of cigarettes smoked per day on average were collected.

HIV-related stigma

Among the measures of HIV-related stigma, the Berger Stigma Scale (Berger et al., 2001), HIV-related Stigma Measure (Sowell et al., 1997), and Internalized AIDS-related Stigma Scale (Kalichman et al., 2009) were most frequently used. The scale developed by Berger et al. (2001) has 40 items with four factors: personalized stigma, disclosure concerns, concerns with public attitudes, and negative self-image. Turan et al. (2017) reframed the four dimensions of HIV stigma as enacted or experienced stigma, anticipated stigma, perceived (community) stigma, and internalized stigma. We used a short 12-item version of the HIV Stigma Scale that shortened the Berger 40-item scale to 12 items, namely, three items for each of the four subscales (Reinius et al., 2017). This short-version scale demonstrated better psychometric properties than the full scale, which was tested with confirmatory factor analysis. Cronbach alphas of subscales were all above 0.7 and considered acceptable (Reinius et al., 2017). Participants responded to the 12 items on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). In this study, we used data only from the perceived stigma (i.e., concerns about public attitudes; e.g., most people believe a person who has HIV is dirty) and internalized stigma (i.e., negative self-image; e.g., I feel guilty because I have HIV) subscales because these two subscales had higher correlations with anxiety and depressive symptoms than personalized stigma and disclosure concerns subscales. Item scores were summed to obtain subscale scores that could range from 1 to 12. Cronbach alphas of perceived and internalized subscales were 0.81 and 0.78, respectively, and Cronbach alpha of the total score was 0.84.

Nicotine dependence

The Fagerstrom Test for Nicotine Dependence (Heatherton et al., 1991) is the most widely used tool for nicotine dependence, and we used this tool in the two parent studies (Kim et al., 2018, 2020). The scale has six items: four dichotomous (0 vs. 1) items and two 4-point (0-3) items. The scale score is the sum of six-item scores ranging from 0 to 10. The higher the score is, the more severe the nicotine dependence is (Heatherton et al., 1991). Cronbach alpha assumes tau equivalence having equal weights for all answer items (Raykov, 1997). Therefore, we assessed a composite reliability coefficient 0.70 recommended for a measure with inequivalent weights (Kim et al., 2020).

Self-efficacy

This variable was assessed using the Self-efficacy Scale (Velicer et al., 1990), which assesses the extent of confidence an individual has in resisting smoking temptation when he or she is faced with nine high-risk situations for smoking (e.g., "When I am upset or in a bad mood," and "When I see or smell someone smoking"). The scale is a 5-point Likert-type scale ranging from 1 (completely unconfident) to 5 (completely confident), and the scale score is the sum of nine-item scores (Kim et al., 2020). A Cronbach alpha of 0.89 was obtained in this study.

Tobacco smoking stigma

We asked participants to answer the extent of their agreement on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree) to these two statements: "Most people think less of a person who smokes" and "Most people believe smoking is a sign of failure." The two items were adapted from the Perceived Stigma of Addiction Scale (Luoma et al., 2010). Cronbach alpha was 0.64, which could be expected considering the small number of items.

Depressive symptoms

In the first study (Kim et al., 2018), depressive symptoms were assessed using the 20-item Center for Epidemiologic Studies-Depression Scale (Radloff, 1977). Participants rated how many days of the last week they had experienced each of the 20 symptoms on a 4-point (0-3) scale. The scale score is the sum of 20-item scores after reversing the scores of four positive-feeling items (Radloff, 1977). Higher scores indicate more depressive symptoms, and a cutoff score of 16 was recommended for clinical depression (Radloff, 1977). A Cronbach alpha of 0.92 was obtained in this study. The Patient Health Questionnaire-9 (Kroenke et al., 2001) was used in the second study (Kim et al., 2020). The questionnaire has nine depressive symptoms, and participants rated how many days of the last 2 weeks they experienced each of the nine symptoms. Answers could range from 0 (not at all) to 3 (nearly every day), with high scores being more depressed (Kroenke et al., 2001). The scale score is the sum of nine-item scores, and scores of 10 and higher indicate clinical depression (Kroenke et al., 2001). A Cronbach alpha of 0.83 was obtained. In the present study, we converted raw scores of the two scales to standard scores (z-scores) to adjust differences in their scale scores (McLeod, 2019).

Anxiety symptoms

We used the Generalized Anxiety Disorder 7-item Scale (Spitzer et al., 2006) in the two parent studies. The scale has seven anxiety symptoms of generalized anxiety disorder, such as "feeling nervous, anxious or on edge" and "not being able to stop or control worrying" (Spitzer et al., 2006). Each item score ranges from 0 (not at all) to 3 (nearly every day), and the scale score is the sum of 7-item scores. The scale had a sensitivity of 89% and a specificity of 82%, with a cutoff score of 10 when compared with the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Spitzer et al., 2006). Cronbach alpha was 0.93 in the present study.

Data Analysis

A meta-analysis of pooled correlation coefficients between depressive and anxiety symptoms with HIV stigma were 0.48 and 0.32, respectively (Rueda et al., 2016). Using the correlation coefficient of anxiety for an effect size of f² (=

Equation (Uncited)

Analyses were performed using STATA 15 (Stata Corp LP, College Station, TX). There was no significant difference in baseline demographic and behavioral data between the two parent studies; therefore, the data were merged and analyzed together. First, descriptive statistics were used for sociodemographic characteristics, HIV characteristics, smoking-related data, and psychosocial variables. Second, correlation coefficients and bivariate and multivariate linear regression analyses were performed to examine the main effects of perceived and internalized HIV-related stigmas, separately and then combined, and tobacco smoking stigma. Third, interaction effects of HIV-related and tobacco smoking stigmas on depressive and anxiety symptoms were estimated. All stigma scores were mean centered before multivariate regression analyses to reduce multicollinearity (Aiken & West, 1991; Kraemer & Blasey, 2004). We used the delta method to approximate the standard errors of stigma variables for their interaction terms (Fernandez, 2020). A p-value < .05 was considered statistically significant.

Results

Descriptive statistics of key study variables are shown in Table 1. Participants were mostly non-Hispanic Black women (69.6%) and women who were never married (38.2%) or separated/divorced/widowed (39.2%). Approximately one-third (33.7%) of them had less than a high school (HS) education, one-fifth (21.8%) completed an HS or HS-equivalent education, and the remaining had at least some years of a college education. Most were either unemployed (25.7%) or disabled (54.5%). Participants had been living with HIV for 19 years on average, and most had CD4⁺ T-cell counts above 500 cells/mm³ with undetectable viral loads (<50 copies/mL). Approximately 95% of the women were on antiretroviral therapy. They smoked 16 cigarettes per day on average at baseline.

Table 1. Descriptive Statistics Among Women Living With HIV (

Time since HIV diagnosis had a significant association (r = -0.34, p < .001) with the total score of HIV-related stigma. Participants living longer years with HIV had less HIV-related stigma. There was no difference in the relationships with years of the diagnosis between perceived and internalized stigmas. Neither age nor education was associated with any HIV-related stigma subscales. None of the sociodemographic data were associated with either depressive or anxiety symptoms. Perceived (r = 0.22, p = .02) and internalized (r = 0.25, p = .01) HIV-related stigma had a significant relationship with tobacco smoking stigma.

There was a strong positive relationship (r = 0.80, p < .001) between depressive and anxiety symptoms. Except for HIV-related and tobacco smoking stigmas, none of the sociodemographic data, HIV characteristics, and smoking-related variables had a significant association with depressive and anxiety symptoms. Therefore, only the two stigma variables were entered in regression analyses. Bivariate regression analyses showed that both perceived and internalized HIV-related stigmas were significantly associated with both depressive and anxiety symptoms (Table 2). In contrast, tobacco smoking stigma was associated with anxiety symptoms only.

Table 2. Bivariate Analyses of the Relationships Between Stigma and Negative Emotions

In a multivariate regression analysis, internalized HIV-related stigma continued to be associated with both depressive and anxiety symptoms irrespective of tobacco smoking stigma (Table 3). However, perceived HIV-related stigma showed no significant association with either depressive or anxiety symptoms when tobacco smoking stigma was entered in the analysis (data not shown). The relationships between tobacco smoking stigma and anxiety symptoms were no longer significant when controlling for HIV-related stigma. There was a significant interaction effect of internalized HIV-related stigma with tobacco smoking stigma on anxiety symptoms (Table 3). As shown in Figure 1, the relationship between tobacco smoking stigma and anxiety symptoms was statistically significant ([beta] (SE) = 1.37 (0.58), t = 2.41, p = .02) only when participants had high internalized HIV-related stigma (1 SD above the mean).

Table 3. Multivariate Analyses of the Relationships With Main and Interaction Effects Between Stigma and Negative Emotions

Figure 1. Line graph showing interaction between internalized HIV-related stigma and tobacco smoking stigma on anxiety symptoms. ns = not significant; a = SD of tobacco smoking stigma; b = SD of internalized HIV-related stigma.

Discussion

To the best of our knowledge, this is one of the first studies examining the intersectionality of HIV-related stigma, tobacco smoking stigma, and depressive and anxiety symptoms among women living with HIV. We hoped to better understand the complex relationships among a variety of levels and types of stigmas experienced by this population. The study found that women living with HIV perceived HIV-related stigma and indeed internalized the stigma in the form of depression and anxiety, which is similar to what Relf et al. (2019) reported. In support of the meta-analysis conducted by Rueda et al. (2016), internalized HIV-related stigma was positively associated with both depressive and anxiety symptoms, irrespective of tobacco smoking stigma. However, perceived HIV-related stigma had no relationship with either depressive or anxiety symptoms when controlling for tobacco smoking stigma. Nevertheless, direct comparison of the findings with the extant body of knowledge is somewhat limited because most studies assessed HIV stigma by combining all four subscale scores (e.g., Aljassem et al., 2016; Duko et al., 2019), internalized subscale only (e.g., Earnshaw et al., 2015), or combining perceived and internalized subscales (e.g., Zeng et al., 2018).

Tobacco smoking stigma was not significantly associated with either depressive or anxiety symptoms when controlling for HIV-related stigma. However, it had a moderating effect of worsening anxiety when women living with HIV also experienced high internalized HIV-related stigma. There could be several explanations for why tobacco smoking stigma was not a significant correlate of depressive and anxiety symptoms when controlling for HIV-related stigma. Although tobacco smoking is increasingly stigmatized, tobacco products are still legal to buy and use. Compared with illegal substance use (Earnshaw et al., 2015) and minority sexual identity (Yang et al., 2020), tobacco smoking might be a less devalued, and thereby less stigmatized, characteristic. Another explanation may be a problem with the measure of tobacco smoking stigma we used. We used a two-item measure that was adapted from the existing measure of the Perceived Stigma of Addiction Scale (Luoma et al., 2010). This relatively brief measure might not be sensitive enough to capture the true nature of tobacco smoking stigma. Finally, the study sample might have been too small to assess the variable while controlling for the effect of HIV-related stigma on the relationship.

In addition, there are several limitations of this study that should be taken into consideration. First, the study is cross-sectional, and causal relationships among the studied variables are unknown. It is not clear whether HIV-related stigma is a predictor of depressive and anxiety symptoms or vice versa. The causal relationship between HIV-related stigma and mental health should be further explored following PLWH over time in a prospective study design. One prospective study reported that people who were depressed at baseline were far more likely to have HIV-related stigma even after 12 months of treatment than those who were not depressed at baseline (Peltzer & Ramlagan, 2011). Second, the present study was conducted with a small sample of women living with HIV. Third, the sample was overrepresented by non-Hispanic Black women, who constitute the largest racial and ethnic group among women living with HIV (Centers for Disease Control and Prevention, 2018). Finally, we excluded women who were currently using any illegal substances, except for marijuana, or who had serious alcohol problems. The rates of smoking are much higher among current substance users for both PLWH (Wardell et al., 2018) and the general population (Campbell et al., 2017; Weinberger et al., 2017). Future studies should include these women in a smoking cessation study and examine the intersectionality of HIV-related stigma with stigmas related to legal (e.g., tobacco and alcohol) and illicit (e.g., opioid and cocaine) substance use.

Unlike the finding by Relf et al. (2019), the present study did not find any direct effect of age on HIV-related stigma. However, the study found significant, positive effects of internalized HIV-related stigma on depression and anxiety and a significant interaction effect of internalized HIV-related stigma and tobacco smoking stigma on anxiety. These findings support the convergence of multiple stigmatized identities proposed by Goffman (1963) and Turan et al. (2019). Future studies should explore whether education and other sociodemographic factors influence the processes of perceived and internalized HIV-related stigmas differently, and how these factors can be leveraged through interventions to minimize the detrimental effect of internalized HIV-related stigma on mental health. Relatedly, future studies should explore whether internalized stigma is the main source of negative mental health outcomes and how researchers can develop an intervention that is effective in blocking internalization of the negative views of HIV/AIDS that are still looming large in society. Fletcher et al. (2020) found that resilience is an important resource for women living with HIV, and an intervention facilitating its process can be helpful for the women to cope with negative views without internalization.

Clinical implications of the findings include understanding the relationship between HIV-related stigma and mental health and learning the intersectionality of HIV-related stigma and tobacco smoking stigma as whole experiences rather than isolated challenges. There is a need for researchers and clinicians at all levels of care to understand how the patient's internalized HIV-related stigma further worsens perceived tobacco smoking stigma. The complex relationship of HIV-related stigma, tobacco smoking stigma, and anxiety will continue if it is not addressed with consideration of the interaction effect of HIV and smoking. Although there is value in using the intersectionality of multiple devalued characteristics to best understand their effects on mental health, clinicians should be cautious that each person may carry them with their own combination of background, personal characteristics, and personal experiences.

Disclosures

The authors report no real or perceived vested interests related to this article that could be construed as a conflict of interest.

Author Contributions

All authors on this article meet the four criteria for authorship as identified by the International Committee of Medical Journal Editors (ICMJE); all authors have contributed to the conception and design of the study, drafted or have been involved in revising this manuscript, reviewed the final version of this manuscript before submission, and agreed to be accountable for all aspects of the work. Specifically, using the CRediT taxonomy, the specific contribution of each author is as follows: Conception & Methodology: S. S. Kim, R. DeMarco; Formal Analysis: S. S. Kim; Funding Acquisition: S. S. Kim, R. DeMarco; Supervision: S. S. Kim; Writing-Original draft: S. S. Kim, R. DeMarco; Writing/Revising: S. S. Kim, R. DeMarco.

Key Considerations

* Tobacco smoking stigma is associated with worse anxiety symptoms among women who have high internalized HIV-related stigma.

* Health care providers should consider the intersectionality of HIV-related stigma with other socially devalued behaviors such as tobacco smoking.

* Understanding how internalized HIV-related stigma and tobacco smoking stigma develops and how it interacts with other intrapersonal and health-related factors should be assessed at each encounter.

* Discussion on the relationship between discrimination and stigma, specifically in women of color living with HIV, with comorbidities and health risk behaviors should occur.

* Offering key interventions related to the mental health effects of internalized HIV-related stigma, such as education, counseling, support groups, journaling, relaxation therapy, and exercise as tolerated to support physical health, should be considered as usual care.

Acknowledgments

This study was partially supported by a Joseph P. Healey Research Grant at the University of Massachusetts Boston (UMB) and UMB and Dana-Farber/Harvard Cancer Center. Comprehensive Partnership Grant (U54 CA156734) to Drs. Kim and DeMarco.

Registration numbers: NCT02898597 and NCT03289676.

References