Subjective social status in relation to the associations between internalized stigmas and missed HIV appointments among MSM who use substances

Men who have sex with men (MSM) living with HIV who use substances often report internalized stigma associated with aspects of their identities and behaviors, which can negatively influence health behaviors including engagement in HIV care. Given the de-valuing nature of stigma, one's perception of their hierarchical rank in society may account for the relationships between internalized stigma and suboptimal engagement in HIV care. This study investigated relationships between internalized stigmas (i.e., linked to HIV-status, sexual orientation, and substance use), subjective social status in relation to one's community and the U.S., and missed HIV appointments among 143 MSM living with HIV who use substances. In bivariate regression models, internalized HIV stigma related to disclosure (OR = 1.46; confidence interval [CI]: 1.02, 2.09), and substance use stigma (OR = 1.07; CI:1.02, 1.12) were associated with greater odds of missing HIV appointments. Self-perception of higher social status in one's community (OR = 0.81; CI: 0.69, 0.96) and the U.S. (OR= 0.80; CI: 0.69, 0.94) were associated with lower odds of missing HIV appointments. Indirect effects models demonstrated that subjective social status in the U.S., but not in one's community, explained variance in the relationship between internalized HIV and sexual orientation stigmas and missing HIV appointments. Results suggest that perceptions of social status in the U.S. may partially account for the associations between internalized HIV and sexual orientation-related stigmas and sub-optimal engagement in HIV care, potentially related to the discriminatory policies and practices across the U.S., in contrast to more liberal states such as where this study took place. Efforts, including policies, are needed to stop the devaluation of people with stigmatized identities nationally, including those living with HIV and those who identify as sexual minorities, to improve the health and well-being of all people.