The Interaction between Race, Ethnicity, Gender, Sexual Orientation, and Age on Internalized HIV-related Stigma in the DC Cohort

Abstract Background Internalized HIV-related stigma can have a negative impact on health outcomes among people with HIV (PWH). A multilevel model, informed by an intersectional framework, is needed to evaluate the interactions between various aspects of one’s identity and their impact on internalized HIV-related stigma. Therefore, we used a Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) to evaluate internalized stigma among PWH. Methods We evaluated a subset of participants in the DC Cohort longitudinal study on PWH who completed a patient reported outcomes (PROs) survey. Participants were sorted into 24 strata of race/ethnicity, gender, sexual orientation, and age. Stigma was evaluated using a self-reported 4-item instrument. We evaluated the individual and strata level impacts of these variables on internalized stigma using MAIHDA. Results We evaluated 1,540 DC Cohort participants with complete strata information, most of which were non-Hispanic Black (80.3%), male (73.1%), gay/lesbian/bisexual (52.1%), and had a mean age of 52.3 years old. Based on the null model, the strata explain 6.96% of the total variance in stigma. This variance was reduced to 1.67% after adjusting for the individual effects of race/ethnicity, gender, sexual orientation, and age. This shows that the main effects of these covariates jointly account for 77.27% of the between-strata stigma variance, while the remaining 22.73% of the between-strata variance is potentially due to the intersectional effects between the covariates. Conclusion Although the individual effects of race/ethnicity, gender, sexual orientation, and age did not explain a large portion of the variance in stigma, nearly a quarter of the between-strata variance in stigma is potentially attributable to the interaction between these covariates.