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Association between intersectional stigma and HIV care engagement among women living with HIV who inject drugs in Kyiv, Ukraine

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BACKGROUND: Stigma continues to be a major barrier to care for people living with HIV. Recent work has drawn attention to the significance of intersectional stigma ' the compounding impacts of stigma related to multiple characteristics such as drug use and HIV status on HIV care outcomes. People who use drugs represent a key population in Ukraine, yet few studies have focused on women living with HIV (WLWH) who inject drugs to understand how layered stigma correlates with care engagement.
METHODS: Surveys were conducted in Kyiv between November 2019-2020 with WLWH who disclosed recent injection drug use. The survey assessed perceptions of internalized and enacted drug use and HIV stigma, HIV care history, drug use experiences, and other demographic characteristics. Univariable and multivariable logistic regression analyses examined associations between experiencing enacted and/or internal stigma related to HIV and/or drug use, with HIV care engagement as the primary outcome.
RESULTS: Among the 306 women surveyed (median age 34 years), 43% reported high internalized stigma related to both HIV and drug use (22% high in either, 35% low in both). Experiences of enacted stigma were reported as: high related to HIV status and drug use (40%), high in either (39%), and low in both (21%). Overall, 55% were engaged in care. In the adjusted model, experiencing internal stigma related to both drug use and HIV status (aOR: 0.52, 95% CI: 0.30, 0.92) and enacted stigma related to both drug use and HIV status (aOR: 0.47, 95% CI: 0.23, 0.95) were significantly associated with lower odds of care engagement, while women who knew their HIV status for more than 5 years were more likely to be engaged in HIV care (aOR: 2.29, 95% CI: 1.35, 3.87) after adjusting for disclosure, demographic characteristics, and injection drug use frequency.
CONCLUSIONS: This study adds to the growing body of evidence that intersectional stigma is a significant factor in HIV care engagement. Our findings underscore the need for additional programs to support women newly diagnosed. Further research and targeted interventions are needed to address the multiple mechanisms and layers of stigma among WLWH who use drugs.