AIDS PATIENT CARE and STDsVolume 20, Number 5, 2006© Mary Ann Liebert, Inc.

Social Stigma Concerns and HIV Medication Adherence

LANCE S. RINTAMAKI, Ph.D.,1 TERRY C. DAVIS, Ph.D.,2 SILVIA SKRIPKAUSKAS, B.A.,3CHARLES L. BENNETT, MD.,1,3 and MICHAEL S. WOLF, Ph.D., M.P.H.1,3

ABSTRACT

The threat of social stigma may prevent people living with HIV from revealing their statusto others and serve as a barrier to HIV treatment adherence. We evaluated the effect of suchconcerns on self-reported treatment adherence using a short, three-item measure among 204people living with HIV. Overall, the mean age of participants was 40.1 years, 45% were AfricanAmerican, and 80% were male. People with high HIV stigma concerns were 2.5 times lesslikely to define and interpret the meaning of CD4 count correctly and 3.3 times more likelyto be nonadherent to their medication regimen than those with low concerns. Concern overrevealing HIV status was the only statistically significant, independent predictor of adher-ence in multivariate analysis. Clinical care directed to individuals living with HIV shouldtherefore include considerations for patient sensitivity to social stigma, such as modificationsto medication schedules and referrals for counseling prior to enrollment in antiretroviral ther-apies.

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INTRODUCTION

OVER THE PAST DECADE, advances in the phar-maceutical treatment for HIV have greatly

increased the health and lifespan of those liv-ing with the disease.1–3 However, in order forthese medications to work effectively, theymust be adhered to with little or no deviationfrom prescribed regimens. When taken im-properly (such as missing or modifying doses),these medications may subsequently fail to pre-vent viral replication, which may then lead to viral resistance.4,5 Studies have shown that even minor deviations to the prescribedmedication regimen, such as missing one ortwo doses per month, can promote such resis-tance.5,6 Moreover, resistant strains of HIV may

be transmitted to others, thus limiting the treat-ment options available to those newly infectedwith these strains.7 Yet, despite the dangers,poor treatment adherence is common amongpeople living with HIV.8–11

The associations between specific patientand regimen characteristics with poor HIVmedication adherence often have been de-scribed in the literature. Characteristics relatedto adherence include: regimen complexity, for-getfulness, desires to avoid medication side effects, inadequate patient knowledge, fam-ily/work responsibilities, depression, medica-tion availability, or a desire to simply havebreaks from the endless routine of takingpills.12 Most of these and other identified fac-tors found to be significantly associated with

1Midwest Center for Health Services and Policy Research, Veteran Affairs Chicago Healthcare System, Chicago,Illinois.

2Louisiana State University Health Sciences Center, Shreveport, Louisiana.3Institute for Healthcare Studies, Feinberg School of Medicine at Northwestern University, Chicago, Illinois.

adherence can be categorized as patient (social,psychological, educational), medication regi-men (complexity), or institution (access to ser-vices) characteristics.13

An overlooked potential barrier to HIV treat-ment adherence is social stigma. Since the be-ginning of the HIV pandemic, people infectedwith HIV and the social groups with whichthey are associated have been stigmatized bythe general population.14,15 The public hysteriaand lack of education surrounding HIV haveled to ubiquitous victim-blaming and social re-pudiation of those infected by the virus.16–18

The resulting stigma has been labeled as themost important social and psychological issueof the HIV experience.19–21 Recent literaturesuggests that the general public’s fear and re-proach surrounding those infected with HIVpersists in the present.14,22,23

Stigma concerns: a conceptual model

Anxiety or fear of being stigmatized definesa person’s concern for HIV stigma. Stigma con-cerns are informed by a person’s (1) under-standing of and attitude towards both HIV andpeople living with the virus, (2) perceptions of

other people’s attitudes toward HIV, and (3)experiences with expressions of fear, bias, ordiscrimination directed at one’s self or otherpeople living with HIV. In turn, stigma con-cerns may then affect a person’s behavior.24

Figure 1 presents our conceptual model forbroadly understanding how stigma concernsmight arise, and the possible pathways throughwhich these concerns might impact health. Forinstance, people living with HIV must navigatethe potentially dangerous terrain of everydaypersonal relationships and decide if, when,how, and to whom they will disclose their HIVstatus.25–27 Knowing that bias and stigmatiza-tion are often consequences of infection, peo-ple with high concerns for stigma may be lesslikely to disclose their HIV status to others ei-ther out of shame or fear of persecution.26,28,29

The HIV medication regimen, however, cancomplicate this process by requiring consump-tion at inopportune times and in less-than-pri-vate environments, such as at work, in restau-rants, or even when entertaining company athome.11,13 As a result, accessing or consumingHIV medications can produce anxiety over po-tentially revealing one’s HIV status to othersand heightens mindfulness of one’s disease

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FIG. 1. Conceptual model of stigma concerns and HIV medication adherence.

state.29 These situations create dilemmas forpeople living with HIV in which they mustweigh the costs of taking their medicationsagainst others learning about their diagno-sis.30,31 In this study, we sought to evaluate theaffects of patient concerns for social stigma onproper adherence to one’s HIV medication reg-imen.

MATERIALS AND METHODS

Participants

A total of 204 consecutive HIV-infected pa-tients receiving medical care between June andSeptember 2001, who were prescribed one ormore antiretroviral medications, and availablefor interviews prior to their physician visit atoutpatient infectious disease clinics at theNorthwestern Memorial Hospital (Chicago site,n � 97) and the Louisiana State UniversityHealth Sciences Center at Shreveport (LSUHSC,n � 107) were recruited for this study. North-western Memorial Hospital is a private acade-mic medical center affiliated with Northwest-ern University, that serves patients residing inmetropolitan Chicago and nearby suburbs. TheLSUHSC Viral Diseases Clinic is a state-fundedcommunity clinic, which serves nine predomi-nantly rural parishes (county-like units) innorthwest Louisiana. The clinic provides a spec-trum of primary care services for HIV/AIDS pa-tients of all ages. Over 80% of the patient pop-ulation at the LSUHSC clinic receives Medicaidor free care. Patients enrolled in their currentregimen for less than 2 weeks were excludedfrom the study, as were those with one or moreof the following conditions, as noted in the med-ical record: (1) dementia; (2) blindness or se-verely impaired vision not correctable with eye-glasses; (3) deafness or hearing problemsuncorrectable with hearing aid; (4) too ill to par-ticipate in the survey.

Measures

Trained research assistants interviewed pa-tients individually in a private room at each re-spective clinic. The interviewer first distributeda self-administered questionnaire, and thenconducted a structured interview that included

a 25-item questionnaire previously developedand pilot tested earlier by the investigators.32

Questions pertained to patient demographic in-formation, drug and alcohol history, HIV carehistory, sources of HIV information, HIV dis-ease knowledge, adherence, and concern forsocial stigma associated with the disease. De-mographic questions included patient age, gen-der, race/ethnicity, level of educational attain-ment, present living situation, employmentstatus, monthly income, and health insurancecoverage.

Open-ended questions were used to assessknowledge of a working definition for bothCD4 lymphocyte count and viral load, includ-ing whether the values of these should go upor down with treatment. A board-certified in-fectious disease physician blinded to patientcharacteristics and other questionnaire resultsclassified CD4 count and viral load knowledgeas correct if the patient could provide a rele-vant description of the terms and the desiredgoals of treatment.ˇUpon ending the structuredinterview, a brief explanation was provided forpatients that answered incorrectly or were un-able to provide any further details.

Patient Medication Adherence Questionnaire

Patients identified their medication and self-reported any recent missed doses using pagescontaining names and color photographs ofcommon HIV medications from a revised ver-sion of a validated, medication adherence ques-tionnaire.33,34 The Patient Medication Adher-ence Questionnaire (PMAQ) requires patientsto identify their medication, then report on amissed dose in the past 4 days for each anti-retroviral agent. Revisions to the PMAQ in-cluded the simplification of items to be moreeasily understood by lower literate patients,and inclusion of visual cues for regimen iden-tification. Patient knowledge of HIV medica-tions was coded as correct if they identified allmedications, or incorrect if they identified thewrong medications or did not report all med-ications in their highly active antiretroviraltherapy (HAART) regimen. Patient antiretro-viral agents, as well as comorbidities and non-HIV prescriptions, were obtained throughmedical chart reviews. Missed doses within the

STIGMA AND ADHERENCE 361

past 4 days were assessed for each medicationin a patient’s HAART regimen. Four questionswere asked regarding whether the patient hadmissed taking a dose yesterday, the day beforeyesterday, 3 days ago, and over the past week-end. Patients were rated as having proper ad-herence if they self-reported no missed dosesin this time period, while those acknowledgingone or more missed doses were considerednonadherent.

Stigma concern

Patients’ concern for HIV-related socialstigma was measured using three items fromthe second section of the PMAQ, which is a 25-item scale that assesses psychosocial barriers toadherence.33 Items included statements relatedto problems associated with adhering toHAART regimens. The three statements thataddressed concern over stigma and the mind-fulness this may cause were: (1) “I am embar-rassed to get my medicines from a drug store,”(2) “I don’t want people to see me take my HIVmedicines,” and (3) “Taking my medicines re-minds me that I have HIV.” Patients wereasked to respond to each statement by endors-ing the item on a 3-point scale (agree, not sure,disagree). A total concern for stigma score wascalculated (range, 3 to 9), with participants cat-egorized as having either low (3–5), moderate(6–7), or high (8–9) concern for HIV-relatedstigma. The use of this measure was supportedby a preliminary principal components analy-sis, where all three items loaded highly on onefactor (0.87, 0.78, and 0.84, respectively) and internal consistency was deemed appropriate(� � 0.72).

Data analysis

�2 and Student’s t tests were used to evalu-ate the association between concern for stigma,patient characteristics, HIV treatment knowl-edge, and self-reported adherence to HAARTregimens. Multivariate logistic regression mod-els were first used to estimate the independentrelationship between concern for stigma andtreatment knowledge outcomes (CD4 count, vi-ral load, medication identification; correct orincorrect), while controlling for sociodemo-graphic and clinical characteristics significantly

associated (p � 0.05) with each particular out-come in bivariate analyses. Multiple logistic re-gression was then used to estimate the inde-pendent relationship between concern forstigma and 100% adherence to antiretroviralregimens (yes or no), while controlling for so-ciodemographic (age, gender, race/ethnicity,education, site) and regimen (number of HIVmedications in regimen) characteristics. Anyadditional clinical factors found to be signifi-cantly associated with adherence were also en-tered into the final model.

RESULTS

Sample characteristics

Overall, the mean age of respondents was40.1 years (standard deviation [SD] � 9.2years), with 45% of the patients being AfricanAmerican, and 80% were male. More than halfof respondents were unemployed, 44% had ahousehold income less than $800 per month,and one third did not carry any health insur-ance. Over 60% of patients reported at leastsome college education. Some differences inpatient characteristics were noted between thetwo sites. Patients in Shreveport were morelikely to report less than a high school educa-tion (15% versus 9%), to be unemployed (65%versus 45%), to report an income less than $800per month (62% versus 25%), and to be unin-sured (53% versus 13%) than Chicago partici-pants.

More than half of the patients also were receiving treatment for a non-HIV–relatedchronic illness. Nearly one third reported re-ceiving mental health services in the past year,while 9% reported recent treatment for alcoholor illicit drug use. Over 70% of the patientswere taking 3 or more antiretroviral medica-tions in addition to a mean of 3 (SD � 2.9) non-HIV prescription medications. Respondentsaveraged 3 (SD � 2.8) primary care visits in thepast six months, and a mean of 5 medical vis-its (SD � 4.9) in the same time period. Forty-four percent of patients reported experiencingminimal concern for stigma, 35% reported amoderate degree, and 21% high concern forstigma as a result of the taking medications forthe disease. No statistically significant differ-

RINTAMAKI ET AL.362

ences were noted between concern for stigmaand patient sociodemographic or clinical char-acteristics.

Treatment knowledge

Over one fourth of patients were unable todescribe CD4 count (26%) or viral load (29%).African American race, less than high schooleducation, unemployed or retired status, Med-

icaid/free care insurance status, presence of co-morbidities, and Shreveport study site weresignificantly associated with lower CD4 countand viral load knowledge (Table 1). Nearly onehalf (48%) of patients could not identify all ofthe medications in their HAART regimenthrough the use of the PMAQ medication listsand color pictures. Patients taking three ormore HIV medications, possessing one or morenon-HIV comorbidities, those not receiving

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TABLE 1. HIV TREATMENT KNOWLEDGE AND MEDICATION ADHERENCE BY

PATIENT DEMOGRAPHIC AND CLINICAL CHARACTERISTICS

Treatment knowledgeMedication

Viral load CD4 count HAART regimen adherenceVariables % correct % correct % correct % adherent

GenderMale 71.8 74.8 55.8 69.9Female 65.9 70.7 39.0 68.3

RaceAfrican American 54.3a 60.9 55.6 60.9a

White 85.9 86.9 48.9 73.7Other 69.2 69.2 53.8 100.0

EducationLess than high school 44.0a 56.0a 40.0b 68.0High school graduate 56.6 64.2 41.5 64.2Some college 81.7 81.7 59.5 72.2

Employment statusUnemployed, retired 63.2a 66.7a 51.8 68.9Employed part or full time 89.0 83.3 53.1 70.2

Monthly incomeLess than $800 65.4 67.9 55.1 69.1$800–$999 70.0 50.0 30.0 63.8$1000–$1499 72.4 79.3 48.3 85.0$1500 or more 79.0 82.3 59.7 69.6

InsurancePrivate insurance 89.3a 85.7b 62.5 78.6Medicare 67.5 77.5 52.5 67.5Medicaid/free care 62.0 66.7 47.2 65.7

Site Chicago 82.5a 87.6a 67.0a 77.3b

Shreveport 59.8 61.7 39.3 62.6Comorbidities

Yes 66.4 69.2 40.2a 71.0No 75.3 79.4 66.0 68.0

HIV medications1–2 antiretroviral agents 64.0 64.0 86.0a 68.03 or more antiretroviral agents 70.9 73.5 25.6 69.1

Mental illness, treated in past 6 monthsYes 68.9 80.3 67.2a 65.6No 71.3 71.3 46.2 71.3

Drug/alcohol abuse, treated in past 6 months

Yes 63.2 73.7 42.1 63.2No 71.4 74.1 53.5 70.3

aSignificant at the p � 0.05 level.bSignificant at the p � .01 level.

mental health treatment in the past 6 months,and those from the Shreveport study site wereless able to correctly identify all of their HIVmedications. High concern for stigma was sig-nificantly associated with a patient’s inabilityto correctly define and interpret the meaningof both a CD4 count and viral load, as well asa greater likelihood to be nonadherent toHAART regimens (Table 1). Multivariateanalyses were performed to evaluate the rela-tionship between status disclosure concernsand knowledge outcomes controlling for so-ciodemographic and clinical patient character-istics found to be significantly associated withCD4 count, viral load (race/ethnicity, educa-tion, employment status, insurance, and site),and medications in regimen (education, co-morbidity, number of HIV medications, historyof mental illness, and site). Patients who re-ported a moderate concern for stigma weremore able to correctly define and interpret themeaning of viral load (adjusted odds ratio[AOR] 2.4, 95% confidence interval [CI] 1.1–5.4), while those who experienced a high con-cern for stigma were less likely to correctly de-fine and interpret the meaning of CD4 count(AOR 0.4, 95% CI 0.2–0.9; Table 2).

Medication adherence

Approximately two thirds of patients (70.6%)were 100% adherent within the past 4 days.African American race and Shreveport site were

both significantly associated with a greater like-lihood for reporting one or more missed dosesin this timeframe (Table 1). In multivariateanalyses evaluating the relationship betweenconcern for stigma and medication adherencewhile adjusting for sociodemographic (age, gen-der, race/ethnicity, education, income, and site)and clinically relevant covariates (number ofmedications in regimen, presence of non-HIVcomorbid conditions), a high concern for stigmawas the only statistically significant, indepen-dent predictor of missed medication doses in thepast 4 days (AOR 3.3, 95% CI 1.4–8.1; Table 3).

DISCUSSION

This study is the first to quantitatively depictthe relationship between concern for socialstigma and HIV medication adherence. Now inthe third decade of the epidemic, both adher-ence and social stigma remain prevalent issuesfor people living with the virus.13,22 Nearly onethird of the patients in our sample were lessthan 100% adherent to their HIV medicationregimen within the past 4 days, and approxi-mately 1 in 5 patients reported high concern forstigma related to their HIV status. In multi-variate analysis, a high degree of concern forstigma was the only statistically significant, in-dependent predictor of nonadherence to one’smedication regimen. Our research demon-strates how concern over social stigma could

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TABLE 2. CRUDE AND ADJUSTED ODDS RATIOS FOR TREATMETN KNOWLEDGE

BY LEVEL OF PERCEIVED HIV-RELATED STIGMA

Perceived HIV-related stigma

Low Moderate HighOutcome variables (n � 89) (n � 72) (n � 43)

Correct definition and interpretation of CD4 count, % 77.5 79.0 58.1Crude OR (95% CI) — 1.5 0.8–3.0 0.3 0.2–0.7Adjusted ORa (95% CI) — 1.4 0.6–2.8 0.4 0.2–0.9Correct definition and interpretation of viral load, % 65.2 81.9 62.8Crude OR (95% CI) — 2.5 1.2–5.0 0.6 0.3–1.2Adjusted OR (95% CI) — 2.4 1.1–5.4 0.6 0.3–1.5Correct identification of all HIV mediciations in current regimen, % 57.3 52.9 41.9Crude OR (95% CI) — 1.0 0.6–1.8 0.5 0.3–1.1Adjusted OR (95% CI) — 1.2 0.5–2.7 0.6 0.2–1.5

Odds ratios (OR) adjusted for all variables previously identified in Table 3 as significantly associated (p � 0.05)with the specified outcome variable.

CI, confidence interval; AOR, adjusted odds ratio.

influence not just a patient’s psychological ex-perience with HIV infection, but medicationpractices and, consequently, treatment efficacyand health outcomes. Several factors should beconsidered when reviewing our results.

First, our finding that concern for HIV-re-lated stigma is associated with poor adherenceto antiretroviral regimens is consistent withprevious qualitative studies of selected patientpopulations; such as women, injection drugusers, and infected patients outside of the typ-ical disease epicenters across the country.35,36

However, we sought to move beyond ex-ploratory analyses and utilized a cross-sec-tional survey of infected patients receiving carein two diverse urban and rural geographic lo-cations, whose experience with the disease andsocial environment may be dramatically dif-ferent. Our research suggests that patients fromthese two cities were unique to one another, buthad a similar experience in their concerns forstigma and how it affected their ability to prop-erly adhere to their medication schedule.

Second, given the seriousness of proper med-ication adherence and the association with concern for HIV-related stigma, care providersshould address stigma-related issues whencounseling patients before they are placed onan antiretroviral regimen. When possible,providers may want to consider prescribingmedications to patients who acknowledge ahigher concern for social stigma that requirefewer dosages or that have schedules thatwould reduce the amount of public exposurethe patient would incur by taking them.42,43 Se-lecting inconspicuous regimens for those mostsensitive to HIV stigma may ultimately im-prove the proper usage of these medicationsamong this group. In addition, psychosocial interventions should be identified that offerstigma-afflicted patients additional social sup-port and resiliency training to mitigate the neg-ative treatment impact of stigma. Research thathelps providers identify stigmatized patients inthe clinical setting is also needed, along withstudies that will eventually evaluate the effi-

STIGMA AND ADHERENCE 365

TABLE 3. PREDICTORS OF NONADHERENCE TO HAART REGIMEN IN PAST FOUR DAYS

1 or more misseddoses in past 4 days,

Characteristic No. % (n � 62) A.O.R.a 95% CI

Age�40 120 30.8 — —41–50 58 34.5 1.3 0.6–2.9�50 26 19.2 0.7 0.2–2.3

GenderMale 163 30.1 — —Female 41 31.7 1.1 0.5–2.6

RaceCaucasaion/Other 112 23.2 — —African American 92 39.1 1.4 0.7–2.9

Education� High school 25 32.0 — —High school graduate 53 35.9 1.1 0.4–3.4� High school 126 27.8 1.1 0.5–2.5

HIV stigmaLow perceived stigma 89 22.5 — —Moderate perceived stigma 72 30.6 1.5 0.7–3.5High perceived stigma 43 32.3 3.3 1.4–8.1

No. of HIV medications in regimen1–2 medications 50 31.6 — —3 or more 117 32.0 0.9 0.5–1.8

Site Chicago 97 22.7 — —Shreveport 107 37.4 1.8 0.5–1.8

aOdds ratios adjusted for all other variable in model; 95% confidence interval provided.HAART, highly active antiretroviral therapy.

cacy of community and clinic-based programsthat support patients’ psychosocial needs andminimize the impact of stigma. These studiesshould, at the same time, determine what pa-tient, provider, and health care system factorsmediate the relationship between social stigmaand HIV medication adherence. In turn, thesefindings will better inform available HIV pro-grams designed to help people cope with anHIV diagnosis.

There are several limitations to our studythat should be acknowledged. We were unableto assess adherence using one or a combinationof other more objective measures, such as random pill counts, medication event mea-surement system caps, or pharmacokinetic lab-oratory assessments. Although we utilized anexisting, validated assessment tool to measureHIV medication adherence,33 patients may underreport missed doses through question-naires. In addition, our measure of concern forHIV-related stigma was a short, three-itemscale derived from a previously validated in-strument, which may lack the sensitivity ofmore in-depth stigma questionnaires. Furtherpsychometric evaluation should be performedto determine the utility of this scale comparedto other available tools that may not be so par-simonious and practical for use in clinical set-tings.44 In addition, the questions used fail todirectly address patient’s potential concernsover the disfiguring side effects of some HIVmedications, such as lipoatrophy and lipo-dystrophy.45 If patients feel embarrassment,shame, or fear of being ostracized because ofdisfiguring side effects resulting from anti-retroviral (ARV) therapies (conceptually dif-ferent from fear of being ostracized for havingHIV), this could lead to intentional nonadher-ence and should be explored in future research.Also, we did not obtain information on routeof transmission, which may have relevance forstigma concerns and, subsequently, adherenceoutcomes. For instance, those who believe theyacquired HIV via injection drug use or hetero-sexual activity may have different levels of con-cern for the stigma around HIV than do thosewho believe they acquired HIV via homosex-ual activity. Neither did our study assess rela-tionships between social support, stigma con-cerns, and adherence. Social support has been

shown to effect adherence rates,46,47 but little isknown about how social support may mediatestigma concerns or how stigma concerns mayprevent access of social support. Finally, ourstudy was based on interviews with a sampleof only 204 patients, potentially limiting ourability to detect statistical and clinically mean-ingful differences in multivariate analyses.However, our study is one of the first to quan-titatively report on the relationship betweensocial stigma and HIV medication adherenceamong a sample of patients from both urbanand rural settings.

Despite these limitations, this study demon-strates the important influence of social stigmaon treatment adherence among people livingwith HIV. Awareness of this important barriermay better inform clinicians caring for thosethat are infected and guide other avenues forfuture research. This study and others like itthat identify barriers to HIV treatment adher-ence are crucial efforts in the ongoing cam-paigns to improve the care of people livingwith HIV and to improve quality of lifethrough maximizing the benefit of efficacioustreatments and minimizing the negative influ-ences on persons with the disease.

ACKNOWLEDGMENTS

Financial support, in part, was given througha research grant from GlaxoSmithKline Phar-maceuticals. Dr. Wolf is supported through acareer development award through the Centersfor Disease Control and Prevention (1 K01EH000067-01).

REFERENCES

1. Burgoyne RW, Rourke SB, Behrens DM, Salit IE.Long-term quality-of-life outcomes among adults liv-ing with HIV in the HAART era: The interplay ofchanges in clinical factors and symptom profile. AIDSBehav 2004;8:151–163.

2. Negredo E, Molto J, Munoz-Moreno JA, et al. Safetyand efficacy of once-daily didanosine, tenofovir andnevirapine as a simplification antiretroviral approach.Antiviral Ther 2004;9:335–342.

3. Murri R, Fantoni M, Del Borgo C, et al. Determinantsof health-related quality of life in HIV-infected pa-tients. AIDS Care 2003;15:581–590.

RINTAMAKI ET AL.366

4. Mannheimer SB, Matts J, Telzak E, et al. Quality oflife in HIV-infected individuals receiving antiretrovi-ral therapy is related to adherence. AIDS Care 2005;17:10–22.

5. Harrigan PR, Hogg RS, Dong WW, et al. Predictorsof HIV drug-resistance mutations in a large anti-retroviral-naive cohort initiating triple antiretroviraltherapy. J Infect Dis 2005;191:339–347.

6. Eldred LJ, Wu AW, Chaisson RE, Moore RD. Adher-ence to antiretroviral and pneumocystis prophylaxisin HIV disease. J Acquir Immune Defic Syndr HumRetrovir 1998;18:117–125.

7. Blackard JT, Mayer KH. HIV Superinfection in the eraof increased sexual risk-taking. Sexu Transm Dis2004;31:201–204.

8. Haubrich R, Richman D. Nevirapine, didanosine, andzidovudine for patients with HIV: The INCAS trial.Italy, Netherlands, Canada, and Australia. JAMA1999;281:130–131.

9. Kastrissios H, Suarez JR, Hammer S, Katzenstein D,Blaschke TF. The extent of non-adherence in a largeAIDS clinical trial using plasma dideoxynucleosideconcentrations as a marker. AIDS 1998;12:2305–2311.

10. Paterson DL, Swindells S, Mohr J, et al. Adherence toprotease inhibitor therapy and outcomes in patientswith HIV infection. Ann Intern Med 2000;133:21–30.

11. Singh N, Berman SM, Swindells S, et al. Adherenceof human immunodeficiency virus-infected patientsto antiretroviral therapy. Clin Infect Dis 1999;29:824–830.

12. Gifford AL, Bormann JE, Shively MJ, Wright BC, Rich-man DD, Bozzette SA. Predictors of self-reported ad-herence and plasma HIV concentrations in patientson multidrug antiretroviral regimens. J Acquir Im-mune Defic Syndr Hum Retrovir 2000;23:386–395.

13. Fogarty L, Roter D, Larson S, Burke J, Gillespie J, LevyR. Patient adherence to HIV medication regimens: areview of published and abstract reports. PatientEduc Couns 2002;46:93–108.

14. Herek GM, Capitanio JP, Widaman KF. HIV-relatedstigma and knowledge in the United States: preva-lence and trends, 1991–1999. Am J Pub Health2002;92:371–377.

15. Herek GM, Glunt EK. An epidemic of stigma. Publicreactions to AIDS. Am Psychol 1988;43:886–891.

16. Cobb M, De Chabert JT. HIV/AIDS and care providerattributions: Who’s to blame? AIDS Care 2002;14:545–548.

17. Dodds S, Blakley T, Lizzotte JM, et al. Retention, ad-herence, and compliance: special needs of HIV-in-fected adolescent girls and young women. J AdolescHealth 2003;33(2 Suppl):39–45.

18. Frierson RL, Lippmann SB. What about mandatoryAIDS testing? J Kentucky Med Assoc 1989;87:66–71.

19. Chung JYM, Magraw MM. A group approach to psy-chosocial issues faced by HIV-positive women. Hos-pital Commun Psychiatry 1992;43:891–894.

20. Crandall CCR. AIDS-related stigmatization and thedisruption of social relationships. J Soc Person Psy-chol 1992;26:398–416.

21. Moneyham L, Seals B, Demi A, Sowell R, Cohen L,Guillory J. Perceptions of stigma in women infectedwith HIV. AIDS Patient Care STDs 1996;10:162–167.

22. National survey shows fear of HIV/AIDS stigma per-sists. AIDS Policy Law 2004;19:2.

23. Herek GM, Capitanio JP. AIDS stigma and sexualprejudice. Am Behav Sci 1999;42:1130–1147.

24. Chesney MA, Smith AW. Critical delays in HIV test-ing and care: The potential role of stigma. Am BehavSci 1999;42:1162–1174.

25. Cline RJ, McKenzie NJ. Interpersonal roulette andHIV/AIDS as disability: stigma and social supporttension. In Braithwaite DO, Thompson TL, eds. Hand-book of Communication and People with Disabilities:Research and Application. Mahwah, NJ: Erlbaum,2000:pp. 467–484.

26. Derlega VJ, Lovejoy D, Winstead BA. Personal ac-counts on disclosing and concealing HIV-positive testresults: weighing the benefits and risks. In: DerlegaVJ, Barbee AP, eds. HIV and Social Interaction. Thou-sand Oaks, CA: Sage, 1998:pp. 147–164.

27. Paxton S. The paradox of public HIV disclosure. AIDSCare 2002;14:559–567.

28. Derlega VJ, Winstead BA, Greene K, Serovich JM, El-wood WN. Perceived HIV-related stigma and HIVdisclosure to relationship partners after finding outabout the seropositive diagnosis. J Health Psychol2002;7:415–432.

29. Rintamaki LS. HIV Identity Trajectories and Social Interaction. Dissertation Abstracts International, A64-11, 3907. University Microfilms International, 2003.

30. Golin CE, Liu H, Hays RD, et al. (2002). A prospec-tive study of predictors of adherence to combinationantiretroviral medication. J Gen Intern Med 2002;17:756–765.

31. Roberts KJ. Barriers to and facilitators of HIV-positivepatients’ adherence to antiretroviral treatment regi-mens. AIDS Patient Care STDs 2000;14:155–168.

32. Wolf MS, Davis TC, Arozullah A, et al. Relation be-tween literacy and HIV treatment knowledge amongpatients on HAART regimens. AIDS Care 2005;17:863–873.

33. DeMasi RA, Graham NM, Tolson JM, et al. Correla-tion between self-reported adherence to highly activeantiretroviral therapy (HAART) and virologic out-come. Adv Ther 2001;18:163–173.

34. DeMasi RA, Tolson J, Pham SV, Capuano GA, FisherRL. Self-reported adherence to HAART and correla-tion with HIV RNA: Initial results with the patientmedication adherence questionnaire. Presented at the6th Conference on Retroviruses and Opportunistic In-fections, Chicago, IL: January 31, 1999.

35. Carr RL, Gramling LF. Stigma: A health barrier forwomen with HIV/AIDS. J Assoc Nurses AIDS Care2004;15:30–39.

36. Cederfjall C, Langius-Eklof A, Lidman K, WredlingR. Self-reported adherence to antiretroviral treatmentand degree of sense of coherence in a group of HIV-infected patients. AIDS Patient Care STDs 2002;16:609–616.

STIGMA AND ADHERENCE 367

37. Mandru N. Stigma and HIV: Does the social responseaffect the natural course of the epidemic? J AssocNurses AIDS Care 2003;14:39–48.

38. Bontempi JM, Burleson L, Lopez MH. HIV medica-tion adherence programs: The importance of socialsupport. J Commun Health Nurs 2004;21:111–122.

39. Demas P, Schoenbaum EE, Wills TA, Doll LS, KleinRS. Stress, coping, and attitudes toward HIV treat-ment in injecting drug users: A qualitative study.AIDS Educ Prev 1995;7:429–442.

40. Reynolds NR, Testa MA, Marc LG., et al. Factors in-fluencing medication adherence beliefs and self-effi-cacy in persons naive to antiretroviral therapy: A mul-ticenter, cross-sectional study. AIDS Behav 2004;8:141–150.

41. Weiss L, French T, Finkelstein R, Waters M, Mukher-jee R, Agins B. HIV-related knowledge and adherenceto HAART. AIDS Care 2003;15:673–679.

42. Ena J, Pasquau F. Once-a-day highly active antiretro-viral therapy: A systematic review. Clin Infect Dis2003;36:1186–1190.

43. Stone VE, Hogan JW, Schuman P, et al. Antiretrovi-ral regimen complexity, self-reported adherence, andHIV patients’ understanding of their regimens: sur-vey of women in the her study. J Acquir ImmuneDefic Syndr Hum Retrovir 2001;28:124–131.

44. Berger BE, Ferrans CE, Lashley FR. Measuring stigmain people with HIV: psychometric assessment of theHIV stigma scale. Res Nurs Health 2001;24:518–529.

45. Milinkovic A, Martinez E. Current perspectives onHIV-associated lipodystrophy syndrome. J Antimi-crob Chemother 2005;56:6–9.

46. Albus C, Schmeisser N, Salzberger B, Fatkenheuer G.Preferences regarding medical and psycho social sup-port in HIV-infected patients. Patient Educ Couns2005;56:16–20.

47. Gonzalez JS, Penedo FJ, Antoni MH, et al. Social sup-port, positive states of mind, and HIV treatment ad-herence in men and women living with HIV/AIDS.Health Psychol 2004;23:413–418.

Address reprint requests to:Michael S. Wolf, Ph.D., M.P.H.Institute for Healthcare Studies

Feinberg School of MedicineNorthwestern University

676 N. St. Clair St., Suite 200Chicago, IL 60611

E-mail: mswolf@northwestern.edu

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