The Moderating Role of Social Support on the Relationship Between Anxiety, Stigma, and Intention to Use Illicit Drugs Among HIV-Positive Men Who Have Sex with Men

  • Phoenix K. H. Mo
  • Xi Chen
  • Eliz H. K. Lam
  • Jinghua Li
  • Christopher W. Kahler
  • Joseph T. F. LauEmail author
Original Paper


The present study examined the association between anxiety, stigma, social support and intention to use illicit drugs, and the moderating role of social support on the association between anxiety/stigma and intention to use illicit drugs among 450 Chinese HIV-positive MSM. Findings show that controlling for significant background variables, self-stigma and anxiety were positively associated with intention to use illicit drugs, while social support was negatively associated with intention to use illicit drugs. A significant moderation effect of social support was also observed, that the negative association between self-stigma/anxiety and intention to use illicit drugs was only significant among participants with lower levels of social support. Findings highlight the importance of reducing self-stigma and anxiety, and promoting social support in drug use prevention for HIV-positive MSM.


Social support Intention to use illicit drugs Anxiety Stigma Men who have sex with men 



We would like to express our heartfelt thanks to Mr. Xiaodong Wang, director of the local NGO, for his support in data collection and coordination.


The study was funded by the Providence/Boston Center for AIDS Research International Developmental Grant [P30AI042853] and the National Natural Science Foundation of China Young Scientists’ Grant [81302479].

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    National Health and Family Planning Commission of the People’s Republic of China. 2015 China AIDS response progress report 2015. [Available from:]
  2. 2.
    NCAIDS C. Update on the AIDS/STD epidemic in China. Chin J Aids STD. 2016;22(10):767.Google Scholar
  3. 3.
    Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–97.PubMedPubMedCentralCrossRefGoogle Scholar
  4. 4.
    Cochran SD, Ackerman D, Mays VM, Ross MW. Prevalence of non-medical drug use and dependence among homosexually active men and women in the US population. Addiction. 2004;99(8):989–98.PubMedPubMedCentralCrossRefGoogle Scholar
  5. 5.
    Kerridge BT, Pickering RP, Saha TD, Ruan WJ, Chou SP, Zhang H, et al. Prevalence, sociodemographic correlates and DSM-5 substance use disorders and other psychiatric disorders among sexual minorities in the United States. Drug Alcohol Depend. 2017;170:82–92.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Greenwood GL, White EW, Page-Shafer K, Bein E, Osmond DH, Paul J, et al. Correlates of heavy substance use among young gay and bisexual men: the San Francisco Young Men’s Health Study. Drug Alcohol Depend. 2001;61(2):105–12.PubMedCrossRefGoogle Scholar
  7. 7.
    Ferrando S, Goggin K, Sewell M, Evans S, Fishman B, Rabkin J. Substance use disorders in gay/bisexual men with HIV and AIDS. Am J Addict. 1998;7(1):51–60.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    O’Cleirigh C, Magidson JF, Skeer MR, Mayer KH, Safren SA. Prevalence of psychiatric and substance abuse symptomatology among HIV-infected gay and bisexual men in HIV primary care. Psychosomatics. 2015;56(5):470–8.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Power R, Koopman C, Volk J, Israelski DM, Stone L, Chesney MA, et al. Social support, substance use, and denial in relationship to antiretroviral treatment adherence among HIV-infected persons. AIDS Patient Care STD. 2003;17(5):245–52.CrossRefGoogle Scholar
  10. 10.
    Harrington RD, Woodward JA, Hooton TM, Horn JR. Life-threatening interactions between HIV-1 protease inhibitors and the illicit drugs MDMA and gamma-hydroxybutyrate. Arch Intern Med. 1999;159(18):2221–4.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Bing EG, Burnam MA, Longshore D, Fleishman JA, Sherbourne CD, London AS, et al. Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the United States. Arch Gen Psychiatry. 2001;58(8):721–8.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Herek GM. AIDS and stigma. Am Behav Sci. 1999;42(7):1106–16.CrossRefGoogle Scholar
  13. 13.
    Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 1991–1999. Am J Public Health. 2002;92(3):371–7.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Dlamini PS, Wantland D, Makoae LN, Chirwa M, Kohi TW, Greeff M, et al. HIV stigma and missed medications in HIV-positive people in five African countries. AIDS Patient Care STD. 2009;23(5):377–87.CrossRefGoogle Scholar
  15. 15.
    Waite KR, Paasche-Orlow M, Rintamaki LS, Davis TC, Wolf MS. Literacy, social stigma, and HIV medication adherence. J Gen Intern Med. 2008;23(9):1367–72.PubMedPubMedCentralCrossRefGoogle Scholar
  16. 16.
    Ware NC, Wyatt MA, Tugenberg T. Social relationships, stigma and adherence to antiretroviral therapy for HIV/AIDS. AIDS Care. 2006;18(8):904–10.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Mo PKH, Mak WWS. Intentionality of medication non-adherence among individuals living with HIV/AIDS in Hong Kong. AIDS Care. 2009;21:785–95.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Dowshen N, Binns HJ, Garofalo R. Experiences of HIV-related stigma among young men who have sex with men. AIDS Patient Care STD. 2009;23(5):371–6.CrossRefGoogle Scholar
  19. 19.
    Lang NG. Stigma, self-esteem, and depression:psychosocial responses to risk of AIDS. Hum Organ. 1991;50:66–72.CrossRefGoogle Scholar
  20. 20.
    Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, Wrubel J, et al. HIV-related stigma: adapting a theoretical framework for use in India. Soc Sci Med. 2008;67(8):1225–35.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Kecojevic A, Wong CF, Corliss HL, Lankenau SE. Risk factors for high levels of prescription drug misuse and illicit drug use among substance-using young men who have sex with men (YMSM). Drug Alcohol Depend. 2015;150:156–63.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Chenard C. The impact of stigma on the self-care behaviors of HIV-positive gay men striving for normalcy. J Assoc Nurses AIDS Care. 2007;18(3):23–32.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Kennedy CE, Baral SD, Fielding-Miller R, Adams D, Dludlu P, Sithole B, et al. ”They are human beings, they are Swazi”: intersecting stigmas and the positive health, dignity and prevention needs of HIV-positive men who have sex with men in Swaziland. J Int AIDS Soc. 2013;16:18749.PubMedPubMedCentralCrossRefGoogle Scholar
  24. 24.
    Beckerman A, Fontana L. Medical treatment for men who have sex with men and are living with HIV/AIDS. Am J Mens Health. 2009;3(4):319–29.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Burnham KE, Cruess DG, Kalichman MO, Grebler T, Cherry C, Kalichman SC. Trauma symptoms, internalized stigma, social support, and sexual risk behavior among HIV-positive gay and bisexual MSM who have sought sex partners online. AIDS Care. 2016;28(3):347–53.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    McCabe SE, Bostwick WB, Hughes TL, West BT, Boyd CJ. The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. Am J Public Health. 2010;100(10):1946–52.PubMedPubMedCentralCrossRefGoogle Scholar
  27. 27.
    Mizuno Y, Borkowf C, Millett GA, Bingham T, Ayala G, Stueve A. Homophobia and racism experienced by Latino men who have sex with men in the United States: correlates of exposure and associations with HIV risk behaviors. AIDS Behav. 2012;16(3):724–35.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Rendina HJ, Millar BM, Parsons JT. Situational HIV stigma and stimulant use: a day-level autoregressive cross-lagged path model among HIV-positive gay and bisexual men. Addict Behav. 2018;83:109–15.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Dew MA, Becker JT, Sanchez J, Caldararo R, Lopez OL, Wess J, et al. Prevalence and predictors of depressive, anxiety and substance use disorders in HIV-infected and uninfected men: a longitudinal evaluation. Psychol Med. 1997;27(2):395–409.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Bertholet N, Cheng DM, Palfai TP, Lloyd-Travaglini C, Samet JH, Saitz R. Anxiety, depression, and pain symptoms: associations with the course of marijuana use and drug use consequences among urban primary care patients. J Addict Med. 2018;12(1):45–52.PubMedCrossRefGoogle Scholar
  31. 31.
    Pufall EL, Kall M, Shahmanesh M, Nardone A, Gilson R, Delpech V, et al. Sexualized drug use (‘chemsex’) and high-risk sexual behaviours in HIV-positive men who have sex with men. HIV Med. 2018;19(4):261–70.PubMedPubMedCentralCrossRefGoogle Scholar
  32. 32.
    Uchino BN, Bowen K, de Grey RK, Mikel J, Fisher EB. Social support and physical health: models, mechanisms, and opportunities. In: Fisher EB, Cameron LD, Christensen AJ, Ehlert U, Guo Y, Oldenburg B, et al., editors. Principles and concepts of behavioral medicine: a global handbook. New York: Springer; 2018. p. 341–72.CrossRefGoogle Scholar
  33. 33.
    Cohen S, Gottlieb BH, Underwood LG. Social relationships and health. In: Cohen S, Underwood LG, Gottlieb BH, editors. Social support measurement and intervention: a guide for health and social scientists. New York: Oxford University Press; 2000. p. 3–25.CrossRefGoogle Scholar
  34. 34.
    Brashers DE, Neidig JL, Goldsmith DJ. Social support and the management of uncertainty for people living with HIV or AIDS. Health Commun. 2004;16(3):305–31.PubMedCrossRefGoogle Scholar
  35. 35.
    Brashers DE, Neidig JL, Haas SM, Dobbs LK, Cardillo LW, Russell JA. Communication in the management of uncertainty: the case of persons living with HIV or AIDS. ComM. 2000;67(1):63–84.Google Scholar
  36. 36.
    Hansen NB, Cavanaugh CE, Vaughan EL, Connell CM, Tate DC, Sikkema KJ. The influence of personality disorder indication, social support, and grief on alcohol and cocaine use among HIV-positive adults coping with AIDS related bereavement. AIDS Behav. 2009;13(2):375–84.PubMedCrossRefGoogle Scholar
  37. 37.
    Bekele T, Rourke SB, Tucker R, Greene S, Sobota M, Koornstra J, et al. Direct and indirect effects of perceived social support on health-related quality of life in persons living with HIV/AIDS. AIDS Care. 2013;25(3):337–46.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Buttram ME, Kurtz SP, Surratt HL. Substance use and sexual risk mediated by social support among black men. J Community Health. 2013;38(1):62–9.PubMedPubMedCentralCrossRefGoogle Scholar
  39. 39.
    Rueger SY, Malecki CK, Pyun Y, Aycock C, Coyle S. A meta-analytic review of the association between perceived social support and depression in childhood and adolescence. Psychol Bull. 2016;142(10):1017–67.PubMedCrossRefPubMedCentralGoogle Scholar
  40. 40.
    Creswell KG, Cheng Y, Levine MD. A test of the stress-buffering model of social support in smoking cessation: is the relationship between social support and time to relapse mediated by reduced withdrawal symptoms? Nicotine Tob Res. 2015;17(5):566–71.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Mizuno Y, Purcell DW, Dawson-Rose C, Parsons JT. Correlates of depressive symptoms among HIV-positive injection drug users: the role of social support. AIDS Care. 2003;15(5):689–98.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Earnshaw VA, Lang SM, Lippitt M, Jin H, Chaudoir SR. HIV stigma and physical health symptoms: do social support, adaptive coping, and/or identity centrality act as resilience resources? AIDS Behav. 2015;19(1):41–9.PubMedPubMedCentralCrossRefGoogle Scholar
  43. 43.
    Edelman EJ, Cole CA, Richardson W, Boshnack N, Jenkins H, Rosenthal MS. Stigma, substance use and sexual risk behaviors among HIV-infected men who have sex with men: a qualitative study. Prev Med Rep. 2016;3:296–302.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Mak WWS, Cheung RYM. Self-stigma among concealable minorities: conceptualization and unified measurement. Am J Orthopsychiatr. 2010;80(2):267–81.CrossRefGoogle Scholar
  45. 45.
    Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Tong X, An D, McGonigal A, Park SP, Zhou D. Validation of the generalized anxiety disorder-7 (GAD-7) among Chinese people with epilepsy. Epilepsy Res. 2016;120:31–6.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Liu J, Cheng Y, Lau JTF, Wu AMS, Tse VWS, Zhou S. The majority of the migrant factory workers of the light industry in Shenzhen, China may be physically inactive. PLoS ONE. 2015;10(8):e0131734.PubMedPubMedCentralCrossRefGoogle Scholar
  48. 48.
    Luo S, Lin C, Feng N, Wu Z, Li L. Stigma towards people who use drugs: a case vignette study in methadone maintenance treatment clinics in China. Int J Drug Policy. 2019;71:73–7.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Chan KY, Yang Y, Zhang KL, Reidpath DD. Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation—a factorial survey of medical students in China. BMC Public Health. 2007;7:280.PubMedPubMedCentralCrossRefGoogle Scholar
  50. 50.
    Ouellette JA, Wood W. Habit and intention in everyday life: the multiple processes by which past behavior predicts future behavior. Psychol Bull. 1998;12(1):54–74.CrossRefGoogle Scholar
  51. 51.
    Smith JP, Book SW. Anxiety and substance use disorders: a review. Psychiatr Times. 2008;25(10):19–23.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Crawford AM. Stigma associated with AIDS: a meta-analysis. J Appl Soc Psychol. 1996;26(5):398–416.CrossRefGoogle Scholar
  53. 53.
    Abel E, Rew L, Gortner EM, Delville CL. Cognitive reorganization and stigmatization among persons with HIV. J Adv Nurs. 2004;47(5):510–25.PubMedCrossRefPubMedCentralGoogle Scholar
  54. 54.
    Rao D, Desmond M, Andrasik M, Rasberry T, Lambert N, Cohn SE, et al. Feasibility, acceptability, and preliminary efficacy of the unity workshop: an internalized stigma reduction intervention for African American women living with HIV. AIDS Patient Care STD. 2012;26(10):614–20.CrossRefGoogle Scholar
  55. 55.
    Clucas C, Sibley E, Harding R, Liu L, Catalan J, Sherr L. A systematic review of interventions for anxiety in people with HIV. Psychol Health Med. 2011;16(5):528–47.PubMedCrossRefPubMedCentralGoogle Scholar
  56. 56.
    Mo PKH, Coulson NS. Online support group use and psychological health for individuals living with HIV/AIDS. Patient Educ Couns. 2013;93(3):426–32.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Broaddus MR, Hanna CR, Schumann C, Meier A. “She makes me feel that I’m not alone”: linkage to Care Specialists provide social support to people living with HIV. AIDS Care. 2015;27(9):1104–7.PubMedPubMedCentralCrossRefGoogle Scholar
  58. 58.
    Sheeran P. Intention – behavior relations: a conceptual and empirical review. Eur Rev Soc Psychol. 2002;12(1):1–36.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Centre for Health Behaviours Research, School of Public Health and Primary CareThe Chinese University of Hong KongShatinHong Kong
  2. 2.The Chinese University of Hong Kong Shenzhen Research InstituteShenzhenChina
  3. 3.Department of PsychologyThe Chinese University of Hong KongShatinHong Kong
  4. 4.Department of Health Policy and Management, School of Public HealthSun Yat-sen UniversityGuangzhouChina
  5. 5.Sun Yat-sen Global Health InstituteSun Yat-sen UniversityGuangzhouChina
  6. 6.Department of Behavioral and Social SciencesBrown University School of Public HealthProvidenceUSA

Personalised recommendations