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 Table of Contents  
Year : 2023  |  Volume : 16  |  Issue : 1  |  Page : 86-91

HIV/acquired immune deficiency syndrome stigma, perceived social support, and medical adherence among HIV/acquired immune deficiency syndrome children: A mediation analysis

Department of Psychology, Faculty of Social Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission09-Feb-2022
Date of Acceptance21-Jun-2022
Date of Web Publication21-Jan-2023

Correspondence Address:
Dr. Swaran Lata
Department of Psychology, Faculty of Social Sciences, Banaras Hindu University, Varanasi - 221 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/kleuhsj.kleuhsj_128_22

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Introduction: The present study brings forward the relationship among HIV/acquired immune deficiency syndrome (AIDS) stigma, perceived social support (PSS), and medical adherence found among HIV/AIDS children. Methodology: A sample of 90 HIV/AIDS-affected children aged 10–18 years from motilal nehru hospital, Allahabad, Uttar Pradesh, India, was selected for the study. Participants were assessed HIV/AIDS stigma, pss, and medical adherence. The tools of descriptive statistics, correlational and regression analysis, and mediation analysis were performed to accomplish the desired objective of the study. Results: Correlational analysis makes it evident that HIV/AIDS stigma is prominently negatively correlated to PSS (r (88) = −0.670, P < 0.01) and medical adherence (r (88) = −0.770, P < 0.01). Taking into consideration hierarchical regression analysis, it was found that the PSS significantly contributed to 33.2% variance in HIV/AIDS stigma and hiv/aids stigma contributed to 55.7% variance in the process of medical adherence. The achieved results of the mediation analyses validate the mediating role of HIV/AIDS stigma in the association between pss and medical adherence (β = 0.20, Confidence interval = 0.003 to 0.057, P = 0.031). Conclusion: These findings contribute to empirical evidence about psychological predictors and the observable consequences of hiv/aids-related stigma.

Keywords: HIV/acquired immune deficiency syndrome children, HIV/acquired immune deficiency syndrome stigma, medical adherence, perceived social support

How to cite this article:
Singh V, Anupriya, Lata S. HIV/acquired immune deficiency syndrome stigma, perceived social support, and medical adherence among HIV/acquired immune deficiency syndrome children: A mediation analysis. Indian J Health Sci Biomed Res 2023;16:86-91

How to cite this URL:
Singh V, Anupriya, Lata S. HIV/acquired immune deficiency syndrome stigma, perceived social support, and medical adherence among HIV/acquired immune deficiency syndrome children: A mediation analysis. Indian J Health Sci Biomed Res [serial online] 2023 [cited 2023 Jan 28];16:86-91. Available from: https://www.ijournalhs.org/text.asp?2023/16/1/86/368313

  Introduction Top

The present estimation regarding HIV/acquired immune deficiency syndrome (AIDS) stands to a number where 37.7 million people are presently involved in a relentless war against HIV/AIDS. Over 1.7 million children (0–14 years) and 680,000 in number have already yielded to it by the year 2020 (UNAIDS, 2020).[1] This stands testimony to a fact that the condition in India is highly deplorable with a population of around 210,000 suffering from the disease (UNAIDS, 2020).[1] Around 410,000 people belonging to the age group of 10 to 24 years were recently infected and 150,000 of this number belonged to the age group of 10 to 19 years. In India, data of PLHIV are 2.8 million (UNICEF, 2020).[2] AIDS holds a large amount of stigma against itself causing a great deal of prejudice and discrimination. The patients, therefore, encounter stigma and prejudice causing much emotional stress. Goffman (1963)[3] describes stigmatization to be an action where the stigmatized individual is depleted and ruined. In contrast to adults, children infected with HIV/AIDS are approached in a more negative manner and they encounter a larger amount of stigma and discriminatory behavior.

Perceived social support (PSS) is inclusive of a diversity of qualities that hail from a person's social milieu and the linkage that exists between a person and his social condition.[4] Studies have helped to reach to the conclusion that PSS negatively predicts psychosocial distress leading to the onset of upsetting events such as depression, anxiety, stress, and health-related outcomes.[5] This occurrence points toward the social paradox that the innocent children who are in a dire need of sympathy at this condition are denied empathy and social compassion the most.

Along with the physiological deformities that they suffer from, special attention also needs to be paid toward the medical care that these patients ought to receive – which may emphasize on the fact that exactly how much medical guidance and treatment is the patient actually pursuing. In lieu of this idea, there are several obstructions that are encountered by patients suffering from HIV/AIDS – they face a quantifiable amount of trouble in keeping up to a high degree of therapeutic adherence. To ensure patient's adherence to the process of treatment, socio-personal institutions of family, school, and immediate friends are considered to be essential and instrumental to make the entire process functional. It is found that in children who are infected with HIV, admittance and adherence to antiretroviral therapy could prolong and revive the quality of their life gradually. Maintaining an adherence to the antiretroviral treatment is a lifelong obligation, which is crucial for not only the patient but also the health-care providers. To examine the following concerns, the present study examines the relationship among HIV/AIDS stigma, PSS, and medical adherence in HIV/AIDS children.

Taking the existing literature as its valid premise, the hypotheses encapsulated were as follows: (a) PSS will be negatively correlated with HIV/AIDS stigma and positively correlated with medical adherence. (b) HIV/AIDS stigma would be negatively correlated with medical adherence. (c) HIV/AIDS stigma would mediate the relationship between PSS with medical adherence.

  Methodology Top


With the help of a purposive sampling, 90 children infected with HIV (53 boys and 37 girls) were recruited from the ART center of the Department of Medicine, Moti Lal Nehru Hospital, Allahabad. The mean age of the group was 13.98 years (boys – 14.38 years and girls –12.15 years) [Table 1]. The inclusion criteria included (a) documented status of HIV/AIDS or on anti-retroviral therapy (ART), (b) ≤18 years of age, (c) proficiency in the Hindi language, (d) knowledge about their HIV status, (e) they have provided informed consent, and (f) they are voluntarily participating in the study anda no compulsion of any sort has been made on them. Exclusion criteria were refusing informed written consent or unwilling to spare time for the study. The study was approved by the Departmental Research Committee, Department of Psychology, Faculty of Social Science, Banaras Hindu University, Varanasi. Ref.No. Psych./Res./September2013/53 (m).
Table 1: Sociodemographic characteristics of HIV/AIDS children

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Sociodemographic characteristics

Sociodemographic characteristics of the participants included age, gender, educational qualification, family background, living status, HIV status of both parents, and the duration of ART (antiretroviral treatment).

HIV/acquired immune deficiency syndrome stigma

The vehement presence of HIV/AIDS stigma was assessed using Berger's HIV/AIDS stigma questionnaire (2001).[6] Through the translation and back translation method, the questionnaire was translated into the Hindi language which would make it possible for the candidates to read and interpret it smoothly. The questionnaire comprised 35 items, using a response option ranging from 1 to 5 (strongly disagree to strongly agree). Cronbach's alpha for the tool in this study was 0.81. A higher score indicated a greater level of stigma.

Perceived social support

The level of PSS was assessed on a 30-item scale developed by[7] using a response option ranging from 1 to 5 (strongly disagree to strongly agree). The Cronbach's alpha coefficient for this tool was 0.87. This study was based on the fact that a greater score directly indicated a greater variable. The greater the score, the greater the level of variable.

Medical adherence

The level of medical adherence was primarily evaluated by enquiring from the HIV/AIDS children if they have missed a particular dose of medication. Scoring was done with the help of three-point Likert scale (ranging from 3 to 1). Three points were allocated to those who missed >12 doses, 2 to those who missed 3–12 doses, and 1 to those who missed <3 doses.

Statistical analysis

First, an assessment formed out of descriptive statistics was computed for sociodemographic characteristics [Table 2]. Second, correlational analysis was performed to investigate the relationship between predictor and criterion variables and the hierarchical regression analysis. Third, mediation analysis was performed to examine the flow how one construct has the ability to consequently affect the second and the third thereafter. Following this process, the Sobel test was applied to find out the significance of the mediating effects of HIV/AIDS stigma on the relationship between the predictor and the criterion variables. To deduce this information, the Statistical Program for the Social Sciences (SPSS version 20.0) IBM, Chicago, United States of America was brought into use and conducive results were achieved.
Table 2: Descriptive statistics for the studied variables

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  Results Top

Descriptive statistics

[Table 3] brings into light the correlational analysis that HIV/AIDS stigma was found to be significantly negatively correlated with PSS (r (88) = −0.670, P < 0.01) and medical adherence (r (88) = −0.770, P < 0.001). As formulated by the afore-mentioned data, the results demonstrate that PSS had been significantly positively correlated with medical adherence (r (88) = 0.606, P < 0.01).
Table 3: Correlation matrix

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Hierarchical regression analysis

Results of hierarchical regression analyses [Table 4] reveal that after bringing into significant control the effect of demographic variables, PSS significantly contributed to the 34.3% of the variance (F change = 47.609, P < 0.001), thereby successfully predicting medical adherence. The positive beta values (β = 0.640, P < 0.001) indicate that the level of PSS has the ability to cause an increase in the level of medical adherence found among children battling the disease of HIV/AIDS.
Table 4: Hierarchical regression analysis with perceived social support as predictor and medical adherence and HIV/AIDS stigma as criterion

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The results achieved from hierarchical regression analyses [Table 5] that were brought in use for predicting HIV/AIDS stigma from PSS surmised that after taking into control the effect of demographic variables, PSS significantly contributed to 33.2% (F change = 55.187, P < 0.001) of the variance in concerns of HIV/AIDS stigma. The negative beta values (β = −0.641, P < 0.001) indicate that the level of PSS resulted in a decrease in the level of HIV/AIDS stigma. Thus, results pointed out the fact that the PSS negatively predicted HIV/AIDS-related stigma.
Table 5: Hierarchical regression analysis with HIV/AIDS stigma as predictor and medical adherence as criterion

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The results achieved from hierarchical regression analyses suggest that after controlling the effect of demographic variables, HIV/AIDS stigma significantly contributed to 55.7% of the variance (F change = 120.710, P < 0.001) in prediction of medical adherence. The negative beta values (β = −0.822, P < 0.001) indicate that the HIV/AIDS-related stigma decreases the medical adherence, which indicates that as the score on HIV/AIDS-related stigma increases, medical adherence subsequently decreases.

Mediation analysis

Mediation role of HIV/acquired immune deficiency syndrome stigma in perceived social support–medical adherence relationship

Results of multiple regression analyses assessed each component of the proposed mediational model. First, PSS was positively associated with medical adherence (β = 0.63, t (88) = 6.90, P < 0.001). Further, it was found that PSS was in actuality negatively associated with HIV/AIDS stigma (β = 0.64, t (88) = −7.42, P < 0.001). Finally, the mediator HIV/AIDS stigma was negatively associated with medical adherence (β = −0.82, t (88) = −10.98, P < 0.001). Because both a and b paths were of considerable significance, mediation analyses were tested using the bootstrapping method with bias-corrected confidence estimates.[8] The 95% confidence interval of the indirect effects was obtained with 1000 bootstrap resample.[9] Mediation analyses affirm the interceding role of HIV/AIDS-related stigma in the relation that exists between PSS and medical adherence (β = 0.20, confidence interval = 0.003–0.057, P = 0.031). Results further indicated that the direct effect of PSS on medical adherence became nonsignificant (β = 0.10, t (88) = 2.19, P = 0.017) when brought into control for HIV/AIDS-related stigma. PSS was associated with approximately 0.43 points lower in medical adherence scores as mediated by HIV/AIDS-related stigma. However, the Sobel test was conducted and mediation was found to be existing in the model (z = 4.69, P < 0.001) [Table 6]. It was found that HIV/AIDS-related stigma mediated the relationship between PSS and medical adherence [Figure 1].
Table 6: Sobel test measuring significance of mediating effect of HIV/AIDS stigma on prediction of medical adherence by perceived social support

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Figure 1: Indirect effect of PSS on medical adherence relationship. PSS: Perceived social support

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  Discussion Top

HIV-infected children reported a below-average level of PSS as we see that they do not receive the adequate amount of support that is required being HIV patients. Medical adherence among these children was reported to be moderate, but in the case of HIV infection, 100% medical adherence is vehemently required.

Results of correlational analysis revealed a significant negative correlation between HIV/AIDS-related stigma and the PSS. Hierarchical regression analysis further supports that PSS significantly decreases the level of stigma among HIV/AIDS children. These children reported that they received a diminutive amount of support from their friends, family, and teachers when the latter come to know about their HIV status. They experience seclusion, discrimination, lonely, socially alienated, negativity, scorn, and latent guilt and aggravate the feeling of stigma.[10],[11],[12] At this juncture, it is primarily compulsory that the immediate family and friend circle of the child extends social support in the form of empathy, compassion, and love.

A significant negative correlation was found between HIV/AIDS-related stigma and medical adherence among HIV/AIDS children. Hierarchical regression analysis further confirms that HIV stigma decreases medical adherence. Children do not want to reveal the status of their health; they constantly experience stress and encounter other mental health issues. These factors become highly responsible for instigating the notion of nonadherence among them. Since these children suffer constantly because of the feeling of shame and guilt that has taken birth within them, they are often found hiding their status and not consuming their medicines. They demonstrate fear in consuming medicine when they are in public often leading to the involuntary skipping of doses and avoidance of medical adherence.[10],[12],[13],[14]

Results of the mediation analysis revealed that HIV/AIDS-related stigma transmits the indirect effects of PSS on medical adherence. It implies that when HIV/AIDS-related stigma is added to the relationship between PSS and the medical adherence, previous relationships further reduce subsequently. Previous research findings indicate that satisfactory PSS encourages adherence to ART treatment in HIV patients.[15],[16],[17]

HIV/AIDS children report about their multifarious experience of HIV-related stigma and show poor response to their antiretroviral medications and treatment. Due to the perceived stigma associated with the disease, children and youth confine themselves favoring isolation along with avoiding going to ART centers because of experiencing shame and disgrace consistently. Family and friends can provide social support to the HIV-infected children and youth in the form of emotional support like showing love and empathy toward them. Health-care providers can render informational support like coming forward with suggestions, advice and awareness related to medication, and tangible support like offering those services and aid related particularly to the disease. Social support can be provided in the form of reminding about taking medicines, discussing their health and personal problems, spending quality time with them, discouraging discrimination and promoting positive lifestyle. All of these factors can help them to confront HIV stigma and help in improving their medical adherence. Thus it is crucial to develop and assimilate a safe condition in perennial HIV care and in the family through which PLHIV can build a trustful relationship with their friends, family and practice disclosure and abilities. A strong association between PSS (buffer function) and medical adherence has been found.[12],[13],[14],[18],[19]

The present study aims to add a growing body of research to pediatric HIV in the Indian context. This study suggests a need for inventive, wide-ranging scientific information through media particularly reaching the rural children in school to impart better knowledge and understanding on HIV/AIDS.

The limitations of the present study include possessing a small sample from a hospital in the state of Uttar Pradesh. These results belonged to a motley group of young individuals and cannot be generalized to be representing the majority of the population of children with HIV in India. Third, this study does not implement intervention studies for the upliftment of the young individuals. This leads to the contention that research in future may attempt to take into consideration an intervention toward the overall development of these young adults.


Varsha acknowledges the ICSSR fellowship.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

UNAIDS. Global HIV & AIDS statistics — Fact sheet; 2020. Available from: https://www.unaids.org/en/resources/fact-sheet. [Last accessed on 2022 Sep 10].  Back to cited text no. 1
UNICEF. Adolescent HIV prevention; 2020. Available from: https://data.unicef.org/topic/hivaids/adolescents-young-people/. [Last accessed on 2022 Sep 10].  Back to cited text no. 2
Goffman E. Stigma: Notes on the Management of Spoiled Identity. Engelwood Cliffs, NJ: Prentice-Hall; 1963.  Back to cited text no. 3
Haber MG, Cohen JL, Lucas T, Baltes BB. The relationship between self-reported received and perceived social support: A meta-analytic review. Am J Community Psychol 2007;39:133-44.  Back to cited text no. 4
Yap MB, Devilly GJ. The role of perceived social support in crime victimization. Clin Psychol Rev 2004;24:1-14.  Back to cited text no. 5
Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale. Res Nurs Health 2001;24:518-29.  Back to cited text no. 6
Verma S, Lata S. Perceived social service of HIV/AIDS orphans: A review. Vulnerable Child Youth Stud 2015;10:243-56.  Back to cited text no. 7
Mackinnon DP, Lockwood CM, Williams J. Confidence limits for the indirect effect: Distribution of the product and resampling methods. Multivariate Behav Res 2004;39:99.  Back to cited text no. 8
Preachers KJ, Hayes AF. Contemporary approaches to assessing mediation in communication research. In: Hayes AF, Slater MD, Synder LB, editors. the Sage Sourcebook of Advanced Data Analysis Methods for Communication Research. Thousand Oaks, CA: Sage; 2008. p. 13-54.  Back to cited text no. 9
Barennes H, Tat S, Reinharz D, Vibol U. Perceived stigma by children on antiretroviral treatment in Cambodia. BMC Pediatr 2014;14:300.  Back to cited text no. 10
Clum G, Chung SE, Ellen JM, Adolescent Medicine Trials Network for HIV/AIDS Interventions. Mediators of HIV-related stigma and risk behavior in HIV infected young women. AIDS Care 2009;21:1455-62.  Back to cited text no. 11
Martinez J, Harper G, Carleton RA, Hosek S, Bojan K, Clum G, et al. The impact of stigma on medication adherence among HIV-positive adolescent and young adult females and the moderating effects of coping and satisfaction with health care. AIDS Patient Care STDS 2012;26:108-15.  Back to cited text no. 12
Rao D, Kekwaletswe TC, Hosek S, Martinez J, Rodriguez F. Stigma and social barriers to medication adherence with urban youth living with HIV. AIDS Care 2007;19:28-33.  Back to cited text no. 13
Li MJ, Murray JK, Suwanteerangkul J, Wiwatanadate P. Stigma, social support, and treatment adherence among HIV-positive patients in Chiang Mai, Thailand. AIDS Educ Prev 2014;26:471-83.  Back to cited text no. 14
Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr 2001;28:47-58.  Back to cited text no. 15
Lehavot K, Huh D, Walters KL, King KM, Andrasik MP, Simoni JM. Buffering effects of general and medication-specific social support on the association between substance use and HIV medication adherence. AIDS Patient Care STDS 2011;25:181-9.  Back to cited text no. 16
Ruanjahn G, Roberts D, Monterosso L. An exploration of factors influencing adherence to highly active anti-retroviral therapy (HAART) among people living with HIV/AIDS in Northern Thailand. AIDS Care 2010;22:1555-61.  Back to cited text no. 17
Bhattacharya M, Rajeshwari K, Saxena R. Demographic and clinical features of orphans and nonorphans at a pediatric HIV centre in North India. Indian J Pediatr 2010;77:627-31.  Back to cited text no. 18
Nyandiko WM, Ayaya S, Nabakwe E, Tenge C, Sidle JE, Yiannoutsos CT, et al. Outcomes of HIV-infected orphaned and non-orphaned children on antiretroviral therapy in western Kenya. J Acquir Immune Defic Syndr 2006;43:418-25.  Back to cited text no. 19


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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