Impact of gender identity- and HIV-related stigmas and psychosocial resources on mental health and alcohol use among transgender women newly diagnosed with HIV in India: a longitudinal cohort study

BACKGROUND: Transgender women (TGW) living with HIV may be subject to intersectional stigma at multiple levels ' enacted (experiences of discrimination/devaluation); anticipated (expectations of discrimination); internalized (negative self-valuation due to stigmatized status) ' that are associated with negative health outcomes, as posited by the health stigma framework. However, few studies have examined the association between stigma and mental health or hazardous alcohol use among TGW living with HIV. We investigated the longitudinal influence of multiple stigmas on depression, anxiety, and alcohol use in TGW living with HIV in India.
METHODS: We enrolled a prospective cohort of 140 TGW newly diagnosed with HIV from 11 Indian states. Participants completed surveys via telephone-interviews at three timepoints ' baseline, three-months, and six-months (Aug. '20 - Oct. '21) ' about enacted, anticipated, and internalized stigmas related to positive HIV status and transgender identity, as well as: gender affirmation in healthcare settings, social support, and resillency resources. Surveys also captured depression (PHQ-9), generalized anxiety (GAD-2), and hazardous alcohol use (AUDIT-C) scores. Longitudinal analyses used multivariable regression with generalized estimating equations (which account for clustering within individuals and provide robust population-averaged estimates of the outcomes) for each of the three outcomes (results reported as ð?? [95% CI]).
RESULTS: Increasing anticipated HIV-stigma (3.2, [1.7,4.7], p<.001), enacted HIV-stigma (3.5, (2, 5.1), p<.001), anticipated TG-stigma (1.7 [.4, 3], p=.01), internalized TG-stigma (3.1 [1.2,4.9], p=.001), and hazardous alcohol use scores (0.1 [0.03,0.2], p=.006) were associated with increased depression; increasing resiliency resources (-0.3 [-0.5,-0.1], p=.002) and gender affirmation in healthcare (-0.08 [-0.2,-0.004], p=.039) was associated with decreased depression. Increasing enacted HIV-stigma (0.9 [0.5,1.3], p<.001) and internalized HIV-stigma (2.1 [1.4,2.8], p<.001) were associated with increased generalized anxiety; increasing gender affirmation(-0.2 [-0.3,-0.1], p<.001), social support(-0.8 [-1.3,-0.3], p=.001.) was associated with decreased generalized anxiety. Finally, increasing gender affirmation in healthcare-settings was associated with lower hazardous alcohol use scores (-.1 [-0.16,-0.004],p=.04).
CONCLUSIONS: Transgender identity- and HIV-specific stigmas strongly impacted depression and anxiety. Increasing levels of psychosocial resources including gender affirmation in healthcare-settings were associated with improved mental health and reduced alcohol use scores. These findings provide empirical evidence for intervention targets for addressing the well-being of TGW newly diagnosed with HIV.