1 - (IOP 21) Evaluating the Impact of Health Literacy, HIV Stigma, and Retention in Care on HIV Health Outcomes

Introduction
Health literacy and HIV stigma are important variables related to retention in HIV care, and ultimately, HIV outcomes. Accordingly, HIV stigma may play a mechanistic role in the relationship of health literacy to HIV outcomes in that knowledge gaps due to poor health literacy may lead to the fear and stigma about having HIV, creating a barrier to accessing or being retained in care. However, research has yet to examine the role of HIV stigma in the relationship between health literacy and retention in care nor how these mechanisms impact HIV-related outcomes.

Methods
The study uses survey and medical chart data from 1,390 people living with HIV (PLWH) who received care from a public, non-profit tertiary care hospital-based clinic that provides care for underserved patients in Miami, Florida. Participants completed the Internalized AIDS-Related Stigma Scale (IA-RSS) and self-report items assessing their health literacy and retention in care. HIV RNA viral load data were obtained through medical chart extraction, which were log transformed. We conducted confirmatory factor analyses (CFA) to examine the fit of hypothesized single-factor models of perceived stigma and health literacy as latent variables. We then conducted a path analysis to test direct and indirect effects of health literacy, retention, and stigma, on baseline and 6-month viral load.

Results
The measurement model with perceived stigma and health literacy as latent variables yielded acceptable fit (CFI = 0.99, TLI = 0.98, SRMR = 0.042, RMSEA = 0.045, CI: 0.036-0.055).
In the final path model (CFI = 0.98, TLI = 0.98, SRMR = 0.030, RMSEA = 0.033, CI: 0.022-0.038), there were both direct and indirect effects (through retention in care) of both health literacy (b = -0.019, p = .009, b = -0.022, p = .018, b = -0.017, p = .047) and of HIV stigma (b = 0.30, p = 0.006, b = 0.35, p = .013, b = 0.26, p = .041) on HIV outcomes (retention in care, log viral load at baseline, and log viral load at 6-month follow up, respectively). Additionally, as health literacy increased b = -0.064, p < 0.001, HIV stigma decreased, with HIV stigma also mediating effects of health literacy on the outcomes.

Discussion
These findings identify mechanisms through which health literacy and stigma can impact key HIV-related outcomes. Higher health literacy may lead to lower perceived HIV stigma, and in turn lead patients to be more motivated to be engaged in care, which can have significant implications for HIV viral load levels throughout the course of HIV-related care. Cognitive behavioral therapy can assist with addressing the cognitive distortions regarding HIV and provide psychoeducation to help increase health literacy, decrease HIV-related stigma, and increase retention in care among PLWH.