Psychosocial complications of HIV/AIDS-metabolic disorder comorbidities among patients in a rural area of southeastern United States

  • Dominica Hernandez
  • Seth C. Kalichman
  • Harold P. Katner
  • Kaylee Burnham
  • Moira O. Kalichman
  • Marnie Hill


As people living with HIV experience longer life-expectancies resulting from antiretroviral therapy, comorbid conditions are increasing, particularly metabolic disorders. There is potential for psychosocial factors such as stigma experiences, depression, and alcohol use to complicate both HIV infection and metabolic disorders, including diabetes mellitus and hyperlipidemia. While the impact of these psychosocial factors on HIV infection alone are widely studied, their role in potentially complicating HIV co-morbid metabolic conditions has received little attention. This study examined the association between HIV-related stigma and depression, and the potential role of alcohol use as a mediating factor in a clinical sample of patients with comorbid HIV infection and metabolic conditions. Results demonstrated that HIV stigma is associated with depression and this relationship is in part accounted for by alcohol use. Our results indicate that interventions aiming to improve the health of people living with HIV and co-morbid metabolic disorders should prioritize addressing alcohol use as it is related to sources of stress, such as stigma, and depression.


HIV stigma Comorbidity Metabolic disease Psychosocial complications Depression Alcohol use 


Compliance with ethical standards

Conflict of interest

Dominica Hernandez, Seth C. Kalichman, Harold P. Katner, Kaylee Burnham, Moira O. Kalichman, and Marnie Hill declare that they have no conflict of interest.

Human and animal rights and Informed consent

All procedures were in accordance with the ethical standards of the institutional research committees and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.


  1. Adewuya, A. O., Afolabi, M. O., Ola, B. A., Ogundele, O. A., Ajibare, A. O., Oladipo, B. F., et al. (2009). Post-traumatic stress disorder (PTSD) after stigma related events in HIV infected individuals in nigeria. Social Psychiatry and Psychiatric Epidemiology, 44, 761–766. CrossRefPubMedGoogle Scholar
  2. Arseniou, S., Arvaniti, A., & Samakouri, M. (2014). HIV infection and depression. Psychiatry and Clinical Neurosciences, 68, 96–109.
  3. Balogun, O., Koyanagi, A., Stickley, A., Gilmour, S., & Shibuya, K. (2014). Alcohol consumption and psychological distress in adolescents: A multi-country study. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 54, 228–234. CrossRefGoogle Scholar
  4. Berger-Greenstein, J. A., Cuevas, C. A., Brady, S. M., Trezza, G., Richardson, M. A., & Keane, T. M. (2007). Major depression in patients with HIV/AIDS and substance abuse. AIDS Patient Care and STDs, 21, 942–955. CrossRefPubMedGoogle Scholar
  5. Bogart, L. M., Wagner, G. J., Galvan, F. H., Landrine, H., Klein, D. J., & Sticklor, L. A. (2011). Perceived discrimination and mental health symptoms among black men with HIV. Cultural Diversity & Ethnic Minority Psychology, 17, 295–302. CrossRefGoogle Scholar
  6. Braithwaite, R. S., & Bryant, K. J. (2010). Influence of alcohol consumption on adherence to and toxicity of antiretroviral therapy and survival. Alcohol Research & Health: The Journal of the National Institute on Alcohol Abuse and Alcoholism, 33, 280–287.Google Scholar
  7. Breet, E., Kagee, A., & Seedat, S. (2014). HIV-related stigma and symptoms of post-traumatic stress disorder and depression in HIV-infected individuals: Does social support play a mediating or moderating role? AIDS Care, 26, 947–951. CrossRefPubMedGoogle Scholar
  8. Brown, J. L., DeMartini, K. S., Sales, J. M., Swartzendruber, A. L., & DiClemente, R. J. (2013). Interventions to reduce alcohol use among HIV-infected individuals: A review and critique of the literature. Current HIV/AIDS Reports, 10, 356–370. CrossRefPubMedGoogle Scholar
  9. Castel, A. D., Kalmin, M. M., Hart, R. L., Young, H. A., Hays, H., Benator, D., et al. (2016). Disparities in achieving and sustaining viral suppression among a large cohort of HIV-infected persons in care—Washington, DC. AIDS Care, 28, 1355–1364. CrossRefPubMedPubMedCentralGoogle Scholar
  10. Chambers, L. A., Rueda, S., Baker, D. N., Wilson, M. G., Deutsch, R., Raeifar, E., et al. (2015). Stigma, HIV and health: A qualitative synthesis. BMC Public Health, 15, 848-015-2197-0. CrossRefGoogle Scholar
  11. Chien, I. C., Lin, C. H., Chou, Y. J., & Chou, P. (2013). Increased risk of hyperlipidemia in patients with major depressive disorder: A population-based study. Journal of Psychosomatic Research, 75, 270–274. CrossRefPubMedGoogle Scholar
  12. Deschenes, S. S., Burns, R. J., Pouwer, F., & Schmitz, N. (2017). Diabetes complications and depressive symptoms: Prospective results from the montreal diabetes health and well-being study. Psychosomatic Medicine. PubMedGoogle Scholar
  13. Dour, H. J., Wiley, J. F., Roy-Byrne, P., Stein, M. B., Sullivan, G., Sherbourne, C. D., et al. (2014). Perceived social support mediates anxiety and depressive symptom changes following primary care intervention. Depression and Anxiety, 31, 436–442. CrossRefPubMedGoogle Scholar
  14. Dube, M. P., & Cadden, J. J. (2011). Lipid metabolism in treated HIV infection. Best Practice & Research Clinical Endocrinology & Metabolism, 25, 429–442. CrossRefGoogle Scholar
  15. Earnshaw, V. A., Smith, L. R., Chaudoir, S. R., Amico, K. R., & Copenhaver, M. M. (2013). HIV stigma mechanisms and well-being among PLWH: A test of the HIV stigma framework. AIDS and Behavior, 17, 1785–1795. CrossRefPubMedPubMedCentralGoogle Scholar
  16. Earnshaw, V. A., Smith, L. R., Cunningham, C. O., & Copenhaver, M. M. (2015). Intersectionality of internalized HIV stigma and internalized substance use stigma: Implications for depressive symptoms. Journal of Health Psychology, 20, 1083–1089. CrossRefPubMedGoogle Scholar
  17. Florescu, D., & Kotler, D. P. (2007). Insulin resistance, glucose intolerance and diabetes mellitus in HIV-infected patients. Antiviral Therapy, 12, 149–162.PubMedGoogle Scholar
  18. Gibbie, T., Hay, M., Hutchison, C. W., & Mijch, A. (2007). Depression, social support and adherence to highly active antiretroviral therapy in people living with HIV/AIDS. Sexual Health, 4, 227–232.CrossRefPubMedGoogle Scholar
  19. Harris, M. I. (1998). Diabetes in america: Epidemiology and scope of the problem. Diabetes Care, 21, C11–C14.CrossRefPubMedGoogle Scholar
  20. Hayes, A. F. (2013). Introduction to meidation, moderation and conditional process analysis: A regression-based approach. New York: The Guilford Press.Google Scholar
  21. Hernandez-Romieu, A. C., Garg, S., Rosenberg, E. S., Thompson-Paul, A. M., & Skarbinski, J. (2016). Is diabetes prevalence higher among HIV-infected individuals compared with the general population? evidence from MMP and NHANES 2009–2010. BMJ Open Diabetes Research & Care. Google Scholar
  22. Holbrook, T. L., Barrett-Connor, E., & Wingard, D. L. (1990). A prospective population-based study of alcohol use and non-insulin-dependent diabetes mellitus. American Journal of Epidemiology, 132, 902–909.CrossRefPubMedGoogle Scholar
  23. Howell, A. N., Leyro, T. M., Hogan, J., Buckner, J. D., & Zvolensky, M. J. (2010). Anxiety sensitivity, distress tolerance, and discomfort intolerance in relation to coping and conformity motives for alcohol use and alcohol use problems among young adult drinkers. Addictive Behaviors, 35, 1144–1147. CrossRefPubMedPubMedCentralGoogle Scholar
  24. Jin, M., Arya, P., Patel, K., Singh, B., Silverstein, P. S., Bhat, H. K., et al. (2011). Effect of alcohol on drug efflux protein and drug metabolic enzymes in U937 macrophages. Alcoholism, Clinical and Experimental Research, 35, 132–139. CrossRefPubMedGoogle Scholar
  25. Justice, A. C., McGinnis, K. A., Tate, J. P., Braithwaite, R. S., Bryant, K. J., Cook, R. L., et al. (2016). Risk of mortality and physiologic injury evident with lower alcohol exposure among HIV infected compared with uninfected men. Drug and Alcohol Dependence, 161, 95–103. CrossRefPubMedPubMedCentralGoogle Scholar
  26. Kalichman, S., Katner, H., Banas, E., & Kalichman, M. (2017). Population density and AIDS-related stigma in large-urban, small-urban, and rural communities of the southeastern USA. Prevention Science: The Official Journal of the Society for Prevention Research. Google Scholar
  27. Kapulsky, L., Tang, A. M., & Forrester, J. E. (2015). Food insecurity, depression, and social support in HIV-infected hispanic individuals. Journal of Immigrant and Minority Health, 17, 408–413. CrossRefPubMedPubMedCentralGoogle Scholar
  28. Lehavot, K., Huh, D., Walters, K. L., King, K. M., Andrasik, M. P., & Simoni, J. M. (2011). Buffering effects of general and medication-specific social support on the association between substance use and HIV medication adherence. AIDS Patient Care and STDs, 25, 181–189. PubMedPubMedCentralGoogle Scholar
  29. Levi-Minzi, M. A., & Surratt, H. L. (2014). HIV stigma among substance abusing people living with HIV/AIDS: Implications for HIV treatment. AIDS Patient Care and STDs, 28, 442–451. CrossRefPubMedPubMedCentralGoogle Scholar
  30. Midde, N. M., Rahman, M. A., Rathi, C., Li, J., Meibohm, B., Li, W., et al. (2016). Effect of ethanol on the metabolic characteristics of HIV-1 integrase inhibitor elvitegravir and elvitegravir/cobicistat with CYP3A: An analysis using a newly developed LC-MS/MS method. PLoS ONE, 11, e0149225. CrossRefPubMedPubMedCentralGoogle Scholar
  31. Morrison-Beedy, D., Carey, M. P., & Tu, X. (2006). Accuracy of audio computer-assisted self-interviewing (ACASI) and self-administered questionnaires for the assessment of sexual behavior. AIDS and Behavior, 10, 541–552. CrossRefPubMedPubMedCentralGoogle Scholar
  32. Nanni, M. G., Caruso, R., Mitchell, A. J., Meggiolaro, E., & Grassi, L. (2015). Depression in HIV infected patients: A review. Current Psychiatry Reports, 17, 530.
  33. National Cholesterol Education Program National Heart, Lung, and Blood Institute National Institutes of Health. (2001). Third report of the national cholesterol education program (NCEP) on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). (No. NIH Publication No. 01-3670).NIH.Google Scholar
  34. O’Brien, T., Nguyen, T. T., & Zimmerman, B. R. (1998). Hyperlipidemia and diabetes mellitus. Mayo Clinic Proceedings, 73, 969–976. CrossRefPubMedGoogle Scholar
  35. Onyebuchi-Iwudibia, O., & Brown, A. (2014). HIV and depression in eastern nigeria: The role of HIV-related stigma. AIDS Care, 26, 653–657. CrossRefPubMedGoogle Scholar
  36. Perkins, I. (2004). Diabetes mellitus epidemiology-classification, determinants, and public health impacts. Journal of the Mississippi State Medical Association, 45, 355–362.PubMedGoogle Scholar
  37. Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.CrossRefGoogle Scholar
  38. Rustad, J. K., Musselman, D. L., & Nemeroff, C. B. (2011). The relationship of depression and diabetes: Pathophysiological and treatment implications. Psychoneuroendocrinology, 36, 1276–1286. CrossRefPubMedGoogle Scholar
  39. Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the alcohol use disorders identification test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption—II. Addiction (Abingdon, England), 88, 791–804.CrossRefGoogle Scholar
  40. Szurkowska, M., Szafraniec, K., Pach, D., Targosz, D., Piwonska-Solska, B., Hubalewska-Dydejczyk, A., et al. (2007). Alcohol consumption and the risk of insulin resistance–population based study. [Spozywanie alkoholu i ryzyko wystqpienia insulinoopornosci–badanie populacyjne]. Przeglad Lekarski, 64, 227–231.PubMedGoogle Scholar
  41. Tebas, P. (2008). Insulin resistance and diabetes mellitus associated with antiretroviral use in HIV-infected patients: Pathogenesis, prevention, and treatment options. Journal of Acquired Immune Deficiency Syndromes (1999), 49, S86–S92. CrossRefGoogle Scholar
  42. Tripathi, A., Liese, A. D., Winniford, M. D., Jerrell, J. M., Albrecht, H., Rizvi, A. A., et al. (2014). Impact of clinical and therapeutic factors on incident cardiovascular and cerebrovascular events in a population-based cohort of HIV-infected and non-HIV-infected adults. Clinical Cardiology, 37, 517–522. CrossRefPubMedGoogle Scholar
  43. Tsai, A. C., Bangsberg, D. R., Frongillo, E. A., Hunt, P. W., Muzoora, C., Martin, J. N., et al. (2012). Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural uganda. Social Science & Medicine (1982), 74, 2012–2019. CrossRefGoogle Scholar
  44. Tsiodras, S., Mantzoros, C., Hammer, S., & Samore, M. (2000). Effects of protease inhibitors on hyperglycemia, hyperlipidemia, and lipodystrophy: A 5-year cohort study. Archives of Internal Medicine, 160, 2050–2056.CrossRefPubMedGoogle Scholar
  45. Turan, B., Budhwani, H., Fazeli, P. L., Browning, W. R., Raper, J. L., Mugavero, M. J., et al. (2017). How does stigma affect people living with HIV? The mediating roles of internalized and anticipated HIV stigma in the effects of perceived community stigma on health and psychosocial outcomes. AIDS and Behavior, 21, 283–291. CrossRefPubMedPubMedCentralGoogle Scholar
  46. VanVoorhis, C., & Morgan, B. (2007). Understanding power and rules of thumb for determining sample sizes. Tutorials in Quantitative Methods for Psychology, 3, 43–50.CrossRefGoogle Scholar
  47. Walli, R., Goebel, F. D., & Demant, T. (1998). Impaired glucose tolerance and protease inhibitors. Annals of Internal Medicine, 129, 837–838.CrossRefPubMedGoogle Scholar
  48. Wellen, K. E., & Hotamisligil, G. S. (2005). Inflammation, stress, and diabetes. The Journal of Clinical Investigation, 115, 1111–1119. CrossRefPubMedPubMedCentralGoogle Scholar
  49. Wierzbicki, A. S., Purdon, S. D., Hardman, T. C., Kulasegaram, R., & Peters, B. S. (2008). HIV lipodystrophy and its metabolic consequences: Implications for clinical practice. Current Medical Research and Opinion, 24, 609–624. CrossRefPubMedGoogle Scholar
  50. Wohl, A. R., Galvan, F. H., Carlos, J. A., Myers, H. F., Garland, W., Witt, M. D., et al. (2013). A comparison of MSM stigma, HIV stigma and depression in HIV-positive latino and african american men who have sex with men (MSM). AIDS and Behavior, 17, 1454–1464. CrossRefPubMedGoogle Scholar
  51. World Health Organization (WHO). (2016). International statistical classification of diseases and related health problems10th revision (5th ed.) WHO Library Cataloguing-in-Publication Data.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Dominica Hernandez
    • 1
  • Seth C. Kalichman
    • 1
  • Harold P. Katner
    • 2
  • Kaylee Burnham
    • 1
  • Moira O. Kalichman
    • 1
  • Marnie Hill
    • 2
  1. 1.University of ConnecticutStorrsUSA
  2. 2.Mercer University Medical SchoolMaconUSA

Personalised recommendations