HIV Stigma and Treatment Interruptions among People Living with HIV in Zimbabwe: An Age-Stratified Analysis

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We examined manifestations of stigma and their associations with ART interruptions among young (18–24 years) and older (25 + years) people living with HIV (PLHIV) in Zimbabwe. Methods This analysis utilized cross-sectional data from the 2021 PLHIV Stigma Index 2.0, implemented by the Zimbabwe National Network of PLHIV in partnership with Global Network of People Living with HIV, The International Community of Women Living with HIV, and UNAIDS. Treatment interruptions were defined as ever interrupting or stopping HIV treatment. Internalized and anticipated stigma scores were categorized as “no”, “low”, “moderate” and “high”. Modified Poisson regression models estimated associations between categorized stigma scores and treatment interruptions, with age-stratified analyses among young and older adults. Results Among 1347 PLHIV who ever initiated ART, 20.9% (36/172) of young adults and 10.3% (121/1175) of older adults reported treatment interruptions. Increasing levels of internalized stigma were associated with higher prevalence of treatment interruptions compared to no stigma (low:adjusted prevalence ratio(aPR) 1.7, 95%CI 1.1–2.6, moderate:aPR 2.6, 95%CI 1.7–3.9, high:aPR 3.5, 95%CI 2.1–5.9). Similar associations were observed with anticipated stigma (low:aPR 2.2, 95%CI 1.5–3.4, moderate:aPR 3.2, 95%CI 1.8–5.7, high:aPR 4.9, 95%CI 2.8–8.7). Among young adults, anticipated stigma was more strongly associated with treatment interruptions compared to older adults, while internalized stigma showed a weaker association. Conclusion Different relationships observed between stigma and treatment interruption across age groups highlight the opportunity for tailored interventions for young adults. Addressing stigma at the interpersonal level may optimize treatment adherence and engagement in care during early adulthood. HIV stigma HIV treatment treatment interruption young adult HIV Zimbabwe Introduction In the context of Zimbabwe’s HIV epidemic, adolescents and young adults ages 15–24 remain disproportionately affected; accounting for one-third of new infections in Zimbabwe despite comprising less than a fifth of the population.[ 1 , 2 ] Young people also face specific barriers when it comes to HIV testing, treatment access, and antiretroviral therapy (ART) adherence, with lower rates of utilization compared to their older counterparts.[ 3 – 5 ] Among all people living with HIV in Zimbabwe, 87% of those who are receiving treatment have achieved viral suppression. However, only 45% of young people living with HIV are estimated to be virally suppressed.[ 6 ] For adolescents and young adults living with HIV, stigma remains a pervasive barrier to initiating and remaining engaged in HIV treatment.[ 7 – 9 ] HIV-related stigma can manifest in different forms: internalized stigma, where individuals adopt negative beliefs about themselves related to their HIV status; anticipated stigma, the expectation of encountering prejudice or discrimination from others based on their HIV status; and enacted stigma, where individuals experience prejudice or discrimination from others because of their HIV status.[ 10 ] For adolescents and young adults living with HIV, the effects of these stigmas are exacerbated by biological and psychosocial development [ 11 , 12 ], and have been shown to impact mental health, ART adherence, and retention in care.[ 13 – 16 ] In Zimbabwe, previous studies have highlighted the specific challenges faced by youth living with HIV, including the complexities of navigating disclosure, sexual relationships, and discrimination while also transitioning into adulthood and encountering issues of acceptance, peer pressure, and the formation of personal identity.[ 12 , 15 , 17 ] The fear of rejection or discrimination can lead to suboptimal adherence and disengagement in HIV care, which may be amplified during a life stage where interpersonal relationships play a critical role in providing support and boosting self-esteem.[ 12 , 18 ] Moreover, older adolescents have a higher prevalence of loss to follow-up and virological failure compared to their younger counterparts, illustrating the challenges associated with transitioning to greater autonomy and independence in treatment management.[ 18 , 19 ] These additional health needs, alongside stigma and discrimination, have led to a higher burden of psychosocial and mental health challenges compared to peers living without HIV.[ 20 , 21 ] Sustained ART adherence is crucial for the health and wellbeing of people living with HIV, but has remained a challenge for youth.[ 3 , 5 ] Interruptions in treatment adherence can result in negative health impacts, including opportunistic infections and onward transmission to sexual partners.[ 5 ] Although numerous studies have demonstrated the link between HIV stigma and decreased ART adherence, few have explored this relationship in the context of young adults’ experiences, perspectives, and needs.[ 9 , 22 ] There is also a limited understanding of the extent to which the association between HIV stigma and treatment interruptions manifest differently for youth compared to older adults. In response, these analyses aim to address this gap by examining different manifestation of stigma – both internalized and anticipated – and their associations with treatment interruptions among young and older adults in Zimbabwe. Methods Study design and population Cross-sectional data collected from the People Living with HIV (PLHIV) Stigma Index 2.0 study in Zimbabwe in 2021 were used for these analyses. The PLHIV Stigma Index 2.0 is a research tool designed by and for people living with HIV and coordinated by an international partnership of the Global Network of People Living with HIV (GNP+), International Community of Women Living with HIV (ICW), and The Joint United Nations Programme on HIV/AIDS (UNAIDS). The Zimbabwe National Network of People Living with HIV (ZNNP+) led the implementation of the PLHIV Stigma Index 2.0 in Zimbabwe, gathering evidence on stigma and discrimination experienced by people living with HIV to inform research, HIV policy development, community mobilization efforts, evidence-based advocacy, and program implementation.[ 23 ] The Stigma Index study places individuals living with HIV at the core of the research process, enabling them to shape both data collection and analysis, including the analyses presented here. In Zimbabwe, the PLHIV Stigma Index 2.0 study was implemented over two months in 2021. Study development, design, and recruitment procedures have been previously described.[ 24 ] Briefly, the Stigma Index sampling approach is standardized across countries, with 75% of respondents recruited through venue-based sampling, and 25% recruited through limited chain referral sampling. The sampling procedure was adapted to align with the local context, relying on the expertise of implementing teams in Zimbabwe. The selected venues included health facilities, community spaces, and hotspots. Community-led organizations, including the Zimbabwe National Network of People Living with HIV (ZNNP+), Gays and Lesbians Association of Zimbabwe (GALZ), Rainbow Coalition Zimbabwe, and Trans and Intersex Rise in Zimbabwe, identified key populations such as men who have sex with men, sex workers, transgender individuals, and people who use drugs. The minimum sample size of 1,387 was calculated using the PLHIV Stigma Index 2.0 Sample Size Calculator [ 25 ], based on the prevalence of healthcare avoidance with a precision of 2.5% at a 95% confidence interval. All ten provinces of Zimbabwe were included. Eligibility criteria included informed written consent, age 18 or older, verbal and written communication ability in English, Shona, or Ndebele, aware of living with HIV for at least 12 months, and physically and mentally able to answer survey questions. Data were collected through interviewer-administered socio-behavioral surveys. Interviewers were people living with HIV recruited from Zimbabwean HIV networks and participated in translation of the questionnaire into Shona and Ndebele, and completed a three-day training on study implementation and interviewing techniques. During structured interviews, study participants were presented with the Stigma Index 2.0 questionnaire verbally, and their responses were electronically recorded using handheld tablets. Measures Outcome The primary outcome was a prior interruption in HIV treatment. This measure was derived from the question “Have you ever interrupted or stopped your HIV treatment?”, which was asked only of individuals who reported currently taking or having previously taken HIV treatment. Responses were dichotomized into ever stopping treatment (answering “yes”) and never stopping treatment (answering “no”). Those who responded with “I don’t know/can’t remember” (2.1%, 29/1376) were excluded from regression models. Exposure Internalized and anticipated stigma were the primary exposures. Internalized stigma was measured through seven survey items. Four items asked participants to “agree” or “disagree” with the following statements: “Being HIV positive makes me feel dirty”, “I feel guilty that I am HIV positive”, “I am ashamed that I am HIV positive”, and “I sometimes feel worthless because I am HIV positive”. Answers were dichotomous; coded as 1 (“agreed”) or 0 (“disagreed”). The remaining three items asked whether HIV status had “positively affected, not affected, or negatively affected” the respondent’s self-confidence, self-respect, and ability to cope with stress. Answers were coded dichotomously as 1 (“negatively affected”) or 0 (“positively affected”, “not affected”, or “N/A”.) The internalized stigma score for each person was derived by summing the responses to these questions, resulting in a total score ranging from zero to seven where a higher score indicates a higher level of internalized stigma. A similar process was followed to determine the anticipated stigma score for each respondent. The seven questions asked respondents to answer “yes” or “no” to the following statements: “I have chosen not to attend gatherings”, “I avoided going to a clinic or hospital when I needed to”, “I have chosen not to apply for job(s)”, “I have chosen not to seek social support”, “I have isolated myself from family and/or friends”, “I decided not to have sex”, and “I hide my HIV status from others”. Answers were dichotomous and coded as 1 (“yes”) or 0 (“no”). For each individual, a total score from zero to seven was obtained by adding each question response to determine the anticipated stigma score. Based on the observed distribution of the internalized and anticipated stigma scores among the analytic sample, cut points were established to categorize the primary exposure variables.[ 26 , 27 ] Both internalized and anticipated stigma measures were grouped into four categories which were conceptualized as: 'no stigma' (score of 0), 'low stigma' (scores 1–2), 'moderate stigma' (scores 3–4), and 'high stigma' (scores 5–7). While there is no standardized approach for categorizing both internalized and anticipated stigma scores with adolescents and young adults, a similar data-driven approach was implemented with other stigma scales for youth in low- and middle-income settings.[ 28 ] Covariates Covariates explored for inclusion in the multivariable model were age, gender, education, employment, racial minority status, and belonging to a social network/support group of PLHIV. Age was categorized as young adults (18–24 years) and older adults (25 years and older). Highest level of education completed was categorized as no education/primary, secondary, and post-secondary education. Work was categorized as unemployed, part-time work, full-time work, or retired. Lastly, social support was dichotomized as being a member of a network/social support group (yes/no). Statistical Analyses All analyses were restricted to respondents who were currently on or had previously initiated HIV treatment. Participants who had never initiated treatment were excluded, as they could not experience treatment interruptions, the primary outcome. Differences in characteristics were descriptively compared across young and older participants. A Pearson’s chi-square (χ²) test was used to compare differences in proportions for categorical variables. Modified Poisson regression models fit with a robust variance estimator were used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% confidence intervals (CI) for the association between each stigma measure and the outcome of ever stopping treatment.[ 29 ] Both internalized and anticipated stigma variables were treated as categorical exposures with four levels (“no”, “low”, “moderate”, and “high”). Adjusted analyses controlled for potential confounders identified a priori using the minority stress model and a systematic literature review, including gender, education, employment, racial minority status, and membership in a social network or support group.(30) Multicollinearity among covariates in the full model was assessed using a threshold variance inflation factor (VIF) of 5.[ 31 ] We stratified the study population by age (young adults and older adults) to assess age-related differences in the relationship between stigma and treatment interruption. To formally explore effect measure modification by age group, we fit models with an interaction term between each categorized stigma score and age group. To determine if effect modification was present, a likelihood ratio test and corresponding p value (alpha = 0.05) was used to compare the main model with the model with the interaction term. Analyses were conducted using Stata 17 statistical software (Statacorp, College Station, Texas).[ 32 ] Ethical considerations The study protocol was reviewed and approved by the Medical Research Council of Zimbabwe. Interviewers received informed consent from participants who received information sheets, details of the study and its objectives, and privacy and confidentiality of data. Analyses of secondary data was reviewed by Johns Hopkins Institutional Review Board and determined exempt from human subject research. Results A total of 1,400 participants were interviewed in the Zimbabwe PLHIV Stigma Index 2.0 study, of whom 1376 who ever initiated HIV treatment were included in descriptive analyses (Table 1 ). Among them, 12.8% (176/1376) were young adults aged 18–24. The sample comprised of 54.2% female (746/1376), 39.8% male (547/1376), and 6% transgender (83/1376) respondents. Unemployment levels were significantly higher among young adults (85/176, 48.3%) compared to older adults (421/1200, 35.1%) (p-value < 0.01). Completing a higher level of education also varied with 67.6% (119/176) of young adults and 59.7% (716/1200) of older adults having completed at least secondary education (p-value < 0.01). Experiences of internalized stigma were reported by 56.3% (99/176) of young adults versus 41.7% (500/1200) of older adults (p-value < 0.01), and experiences of anticipated stigma were reported by 73.9% (130/176) of young adults versus 51.8% (621/1200) of older adults (p-value 24 years) (n = 1376) (n = 176) (n = 1200) n % n % n % χ 2 p-value Sex assigned at birth 0.14 Female 767 55.7 89 50.6 678 56.5 Male 609 44.3 87 49.4 522 43.5 Gender 0.17 Cis Female 746 54.2 87 49.4 659 54.9 Cis Male 547 39.8 74 42.1 473 39.4 Transgender woman 62 4.5 13 7.4 49 4.1 Transgender man 21 1.5 2 1.1 19 1.6 Racial, Ethnic or Religious Minority 591 43.0 74 42.1 517 43.1 0.80 Education < 0.01 No education/primary 390 28.3 26 14.8 364 30.3 Secondary 835 60.7 119 67.6 716 59.7 Post-secondary 151 11.0 31 16.6 120 10.0 Work < 0.01 Unemployed 506 36.8 85 48.3 421 35.1 Part-time work 437 31.8 50 28.4 387 32.3 Full-time work 397 28.9 40 22.7 357 29.8 Retired 36 2.6 1 0.6 35 2.9 Member of Network/Support Group 1025 74.5 135 76.7 890 74.2 0.47 Internalized Stigma < 0.01 None 777 56.4 77 43.8 700 58.3 Low 289 21.0 33 18.8 256 21.3 Moderate 240 17.4 49 27.8 191 15.9 High 70 5.1 17 9.7 53 4.4 Anticipated Stigma < 0.01 None 625 45.4 46 26.1 579 48.3 Low 605 44.0 99 56.3 506 42.2 Moderate 90 6.5 24 13.6 66 5.5 High 56 4.1 7 4.0 49 4.1 Among 1347 PLHIV who ever initiated ART, 20.9% (36/172) of young adults and 10.3% (121/1175) of older adults reported treatment interruptions. Across all age groups, respondents who reported low (adjusted prevalence ratio (aPR) 1.7, 95% confidence interval (CI) 1.2–2.9), moderate (aPR 2.6, 95% CI 1.7–3.9), and high (aPR 3.5, 95% CI 2.1–5.9) levels of internalized stigma experienced a higher prevalence of treatment interruptions compared to those reporting no internalized stigma (Table 2 ). Similarly, increasing levels of anticipated stigma were each associated with a higher prevalence of treatment interruptions compared to no anticipated stigma. Individuals with low (aPR 2.2, 95% CI 1.5–3.4), moderate (aPR 3.2, 95% CI 1.8–5.7), and high (aPR 4.9, 95% CI 2.8–8.7) levels of anticipated stigma had an increased prevalence of treatment interruption in comparison to those reporting no anticipated stigma (Table 2 ). Table 2 Prevalence ratios for the association of internalized and anticipated stigma with ever stopping treatment a among PLHIV in Zimbabwe. PR 95% CI aPR b 95% CI Internalized stigma No - - - - Low 1.9** 1.2–2.9 1.7* 1.1–2.6 Moderate 3.1*** 2.1–4.7 2.6*** 1.7–3.9 High 4.8*** 2.9–7.9 3.5*** 2.1–5.9 Anticipated stigma No - - - - Low 2.5*** 1.7–3.7 2.2*** 1.5–3.4 Moderate 4.3*** 2.5–7.5 3.2*** 1.8–5.7 High 6.4*** 3.7–11.2 4.9*** 2.8–8.7 Abbreviations: PR, prevalence ratio; CI, confidence interval. a Those who responded “I don’t’ know/can’t remember” to ever stopping treatment were excluded b Adjusting for age, gender, education, employment, racial minority, and belonging to a social network/support group *p<0.05 ***p<0.001 In age stratified analyses, adjusted prevalence ratios for ever stopping treatment showed no significant association with low, moderate, or high levels of internalized stigma among young adults (Table 3). In contrast among older adults, those with low (aPR 1.6, 95% CI 1.0-2.7), moderate (aPR 2.9, 95% CI 1.9-4.6), and high (aPR 3.7, 95% CI 2.0-6.8) levels of internalized stigma had significantly higher prevalence of treatment interruption compared to individuals reporting no internalized stigma. Regarding anticipated stigma, in both age groups, individuals with low levels of stigma experienced a higher prevalence of treatment interruptions compared to those reporting no anticipated stigma (young adults: aPR 3.1, 95% CI 0.90-10.5; older adults: aPR 2.1, 95% CI 1.4-3.3). The prevalence ratio increased with moderate (young adults: aPR 6.6, 95% CI 1.7-25.9; older adults: aPR 2.6, 95% CI 1.3-5.1) and high (young adults: aPR 8.6, 95% CI 1.8-41.9; older adults: aPR 4.4, 95% CI 2.3-8.3) levels of anticipated stigma, although precision was low. Table 3 : Prevalence ratios for the association of internalized and anticipated stigma with ever stopping treatment a among PLHIV in Zimbabwe, stratified by young vs. older adult status. Young adults Older adults PR 95% CI aPR b 95% CI PR 95% CI aPR b 95% CI Internalized stigma No - - - - - - - - Low 1.8 0.71-4.7 1.7 0.66-4.5 1.8* 1.1-3.0 1.6 1.0-2.7 Moderate 1.8 0.75-4.1 1.6 0.64-3.8 3.4*** 2.2-5.3 2.9*** 1.9-4.6 High 3.1* 1.2-8.1 2.7 0.98-7.2 4.8*** 2.7-8.7 3.7*** 2.0-6.8 Anticipated stigma No - - - - - - - - Low 3.2 0.94-10.6 3.1 0.90-10.5 2.3*** 1.5-3.5 2.1** 1.4-3.3 Moderate 6.3** 1.7-23.2 6.6** 1.7-25.9 3.4*** 1.7-6.6 2.6** 1.3-5.1 High 8.8** 2.0-39.1 8.6** 1.8-41.9 6.0*** 3.3-10.9 4.4*** 2.3-8.3 Abbreviations: PR, prevalence ratio; CI, confidence interval. a Those who responded “I don’t’ know/can’t remember” to ever stopping treatment were excluded b Adjusting for age, gender, education, employment, racial minority, and belonging to a social network/support group *p<0.05 **p<0.01 ***p<0.001 The likelihood ratio test showed insignificant interaction effects of age with internalized and anticipated stigma on treatment interruption with test statistics of 1.7 and 0.3, and p-values of 0.20 and 0.61 for internalized stigma and anticipated stigma, respectively. Discussion In these analyses of Zimbabwe’s PLHIV Stigma Index data, we found the prevalence of treatment interruptions is twice as high among young adults compared to older adults, and higher levels of internalized and anticipated stigma were associated with treatment interruptions among people living with HIV. Notably, the magnitude and precision of these associations varied between young and older adults living with HIV. To date, few studies have compared the relationship between diverse facets of HIV-related stigma on ART utilization across age groups. The age-stratified prevalence ratios presented here indicate a stronger association between elevated anticipated stigma levels and treatment interruptions in young adults in contrast to the association observed among older adults. Conversely, the association between heightened internalized stigma and increased prevalence of treatment interruptions is weaker among young adults in contrast to older adults. As youth living with HIV transition into greater independence and continue to discover and assert their own sexual identities, addressing these barriers to ensure sustained engagement in HIV treatment represents an urgent public health priority. Internalized and anticipated stigma were associated with a higher prevalence of ever stopping HIV treatment, reinforcing the importance of multilevel interventions addressing stigmas to improve HIV care continuity for people living with HIV. The association between higher stigma levels and treatment interruptions aligns with previous research across diverse populations and socio-cultural contexts, highlighting the role of stigma in the HIV care continuum.[9] At the individual level, internalized stigma has been shown to influence treatment adherence through depression, decreased motivation and behavioural skills, and lowered self-esteem.[12–14,33] At the interpersonal level, anticipated stigma has been observed to create a sense of fear of inadvertent disclosure or potential negative consequences of taking treatment, which can undermine self-efficacy and adherence.[16,33,34] The effects of internalized and anticipated stigma on treatment and health outcomes among people living with HIV highlight the need for mitigating stigma as means to improve both the quality and quantity of life among people living with HIV in Zimbabwe and beyond. The assessment of effect measure modification did not reveal statistical differences in effect estimates by age; however, there were noticeable differences in the magnitude of each association across age strata. While heightened levels of internalized stigma were associated with treatment interruption among older adults, the same significant relationship was not observed among young adults. The 'life course perspective' suggests that attitudes toward HIV formed in one's formative years shape how individuals perceive their identity in relation to HIV.[35] Increased ART access and efforts by organizations, like ZNNP+ and GALZ, have helped normalize HIV as a medical condition over time, potentially explaining why internalized stigma affects young adults to a lesser degree than older adults.[12,36–38] In contrast, studies in the United States show older gay, bisexual, and other men who have sex with men (MSM) living with HIV exhibit less internalized stigma, with internalized stigma predicting ART non-adherence in young MSM but not older MSM.[39,40] These differences likely stem from the unique challenges and dynamics experienced by each population and context. Understanding the nuanced age-related differences in treatment interruption in the context of Zimbabwe highlights the imperative to recognize young adults living with HIV as distinct from older adults living with HIV. This differentiation can enable the development of age-specific interventions tailored to the unique needs and challenges at various life stages. The findings from these analyses also suggest that the fear or expectation of discrimination and rejection from others may have a greater influence on treatment interruption than the internalization of negative social attitudes and beliefs. Previous research has demonstrated the impact of anticipated stigma on decreasing treatment adherence among young people living with HIV in Zimbabwe.[7,18,33] During ‘emerging adulthood,’ a phase marked by identity development and social integration, young adults may be especially sensitive to peer judgment and acceptance.[12,41] This transitional period can be pivotal in shaping feelings of anticipated stigma, which has been shown to disrupt interpersonal relationships among people living with HIV, leading to a loss of social support and social disengagement.[42] Conversely, young adults living with HIV with strong bonds to family, friends, and neighbours are better equipped to overcome barriers to ART adherence.[43] The strong influence of anticipated stigma on treatment outcomes among young adults in this study suggest strategies should prioritize addressing anticipated stigma that actively engage with social networks and community dynamics to create supportive environments and challenge stigma at the interpersonal level. This study has several limitations. First, we were unable to directly measure treatment adherence using methods such as pill counts or drug levels, as the relies on self-reported interruption or stopping of treatment. This question likely oversimplifies the complexities of treatment adherence by categorizing individuals as having interrupted treatment, regardless of frequency or duration of interruptions. However, we assumed those reporting interruptions were less likely to adhere than those who reported never interrupting treatment. Second, few standardized internalized and anticipated stigma scales exist, particularly for youth. However, we adapted an internalized stigma score and generated an anticipated stigma score capturing dimensions of anticipated stigma within different social contexts.[44,45] We used a data-driven approach to inform cut points of no, low, moderate, and high stigma rather than determining strata a priori , which may not be directly comparable to other contexts or populations. Third, resulting prevalence ratios in stratified analyses exhibited wide 95% confidence intervals, likely due to the small sample size of young adults in this study, comprising only 172 individuals. Moreover, while we did observe statistical effect measure modification by age, it’s likely our sample was not sufficiently powered to detect these effects. Further investigation is warranted to better understand the dynamics of internalized and anticipated stigma on treatment adherence among young adults living with HIV. Lastly, the questions that determined the exposure and outcome were not timebound. The cross-sectional design of the study did not allow us to determine if experiencing internalized or anticipated stigma preceded treatment interruption within this sample. A longitudinal design and, or combined with, qualitative interviews and case studies could better facilitate examination of the temporal sequence and establish causal relationships between these variables. Conclusion Given the prevalence of HIV among youth that will transition into adulthood and out of pediatric care in Zimbabwe and Sub-Saharan Africa, research and interventions tailored specifically to the needs of young adults are critical.[46,47] In this study, we observed different relationships between internalized stigma and treatment interruptions among age groups, with young adults living with HIV who reported treatment interruptions to be more affected by anticipated stigma than internalized stigma. In response to our findings, a multifaceted approach to combat anticipated stigma among young adults living with HIV in Zimbabwe could be a powerful strategy to improve continuity of treatment. Ongoing efforts in Zimbabwe, led by ZNNP+, to specify ongoing stigma interventions have highlighted gaps in addressing attribute-specific and intersectional stigmas. These data highlight the potential impact of efforts to challenge stigma and discrimination at the interpersonal level to foster a more supportive network for young adults living with HIV.[48–50] Additionally, recommendations within the upcoming Zimbabwe multi-sectoral response plan advocate for the prioritization of interventions that focus on internalized stigma. Our research suggests that future recommendations consider expanding on these guidelines to include a distinct focus on anticipated stigma, particularly among youth. Finally, we advocate for the focus on young adults, distinct from older adults, in both research and program implementation, ensuring that interventions are designed with the specific needs of young adults in mind. Recognizing younger people living with HIV and their unique developmental challenges and social contexts, will be pivotal in maximizing service engagement of young people as a means of improving individual and population-level health outcomes in Zimbabwe. Declarations Ethics approval and consent to participate The study protocol was reviewed and approved by the Medical Research Council of Zimbabwe (Approval number MRCZ/A/2739). Interviewers received informed consent from participants who received information sheets, details of the study and its objectives, and privacy and confidentiality of data in accordance with the Declaration of Helsinki. Analyses of secondary data was reviewed by Johns Hopkins Institutional Review Board and determined exempt from human subject research (IRB0007442). Consent for publication Not applicable Availability of data and materials The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Competing interests The authors have no conflicts of interest to disclose. Funding This research was funded, in part, by the U.S. National Institute of Allergy and Infectious Diseases under award R01AI170249, and by the U.S. National Institute of Mental Health under awards K01MH129226, R01MH132150, and P30MH136919. The Stigma Index 2.0 was made possible with financial support from UNAIDS. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Author’s contributions T.M. and T.Mw. led study implementation and data collection in Zimbabwe, in partnership with O.S., P.L., K.L., J.A., F.C., S.B., K.D., L.S., C.G., and D.M., who all contributed to the study's conception, design, and data acquisition. V.C. performed data analysis and led manuscript writing. K.R., along with other colleagues G.T., A.R., C.L., H.M., and S.Ba., supported data analysis and critically reviewed the manuscript. All authors reviewed, revised, and approved the final version of the manuscript presented for publication. Acknowledgements We wish to acknowledge the participants—people living with HIV—in Zimbabwe who generously shared their time and experiences. We are grateful to the data collection teams and community-led organizations in Zimbabwe that supported the implementation of the People Living with HIV Stigma Index 2.0. References AIDSinfo | UNAIDS [Internet]. [cited 2023 Aug 12]. 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Available from: https://www.stigmaindex.org/wp-content/uploads/2023/11/PLHIV-Stigma-Index-Global-Report-2023-2.pdf Global Network of People Living with HIV (GNP+), International Community of Women Living with HIV (ICW), & Joint United Nations Programme on HIV/AIDS (UNAIDS). (2023). The People Living with HIV Stigma Index global findings report 2023 . https://www.stigmaindex.org/wp-content/uploads/2023/11/PLHIV-Stigma-Index-Global-Report-2023-2.pdf Global Network of People Living with HIV (GNP+). Sample Size Calculator [Internet]. Available from: https://www.stigmaindex.org/library/sample-size-calculator/ Nugent C, Rosato M, Hughes L, Leavey G. Risk factors associated with experienced stigma among people diagnosed with mental ill-health: a cross-sectional study. Psychiatr Q. 2021 Jun 1;92(2):633–43. Oke OO, Akinboro AO, Olanrewaju FO, Oke OA, Omololu AS. Assessment of HIV-related stigma and determinants among people living with HIV/AIDS in Abeokuta, Nigeria: A cross-sectional study. SAGE Open Med. 2019 Aug 8;7:2050312119869109. Gavan L, Hartog K, Koppenol-Gonzalez GV, Gronholm PC, Feddes AR, Kohrt BA, et al. Assessing stigma in low- and middle-income countries: A systematic review of scales used with children and adolescents. Social Science & Medicine. 2022 Aug 1;307:115121. Chen W, Qian L, Shi J, Franklin M. Comparing performance between log-binomial and robust Poisson regression models for estimating risk ratios under model misspecification. BMC Medical Research Methodology. 2018 Jun 22;18(1):63. Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull. 2003 Sep;129(5):674–97. James G, Witten D, Hastie T, Tibshirani R. An Introduction to Statistical Learning [Internet]. New York, NY: Springer; 2013 [cited 2024 Mar 5]. (Springer Texts in Statistics; vol. 103). Available from: http://link.springer.com/10.1007/978-1-4614-7138-7 StataCorp. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC; 2021. Masa R, Zimba M, Tamta M, Zimba G, Zulu G. The association of perceived, internalized, and enacted HIV stigma with medication adherence, barriers to adherence, and mental health among young people living with HIV in Zambia. Stigma and Health. 20220804;7(4):443. Kalichman S, Mathews C, El-Krab R, Banas E, Kalichman M. Forgoing antiretroviral therapy to evade stigma among people living with HIV, Cape Town, South Africa. J Behav Med. 2021 Oct 1;44(5):653–61. Cahill S, Valadéz R. Growing Older With HIV/AIDS: New Public Health Challenges. Am J Public Health. 2013 Mar;103(3):e7–15. O’Brien S, Broom A. HIV in Harare: The role and relevance of social stigma. African Journal of AIDS Research. 2014 Oct 2;13(4):339–49. Human Dignity Trust. Human Dignity Trust. 2019 [cited 2023 Jun 27]. Zimbabwe. Available from: https://www.humandignitytrust.org./country-profile/zimbabwe/ Goddard K. A Fair Representation. Journal of Gay & Lesbian Social Services. 2004 Jan 1;16(1):75–98. Batchelder AW, Burgess C, Perlson J, O’Cleirigh C. Age and Year of HIV Diagnosis Are Associated with Perceptions of Discrimination and Internalized Stigma Among Sexual Minority Men Who Use Substances. AIDS Behav. 2022 Jan;26(Suppl 1):125–37. Mutchler MG, Bogart LM, Klein DJ, Wagner GJ, Klinger IA, Tyagi K, et al. Age matters: differences in correlates of self-reported HIV antiretroviral treatment adherence between older and younger Black men who have sex with men living with HIV. AIDS Care. 2019 Aug;31(8):965–72. Arnett JJ. Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist. 2000;55(5):469–80. Wanjala SW, Nyongesa MK, Mapenzi R, Luchters S, Abubakar A. A qualitative inquiry of experiences of HIV-related stigma and its effects among people living with HIV on treatment in rural Kilifi, Kenya. Frontiers in Public Health [Internet]. 2023 [cited 2023 Jun 29];11. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1188446 Ajuna N, Tumusiime B, Amanya J, Awori S, Rukundo GZ, Asiimwe JB. Social Networks and Barriers to ART Adherence Among Young Adults (18–24 years) Living with HIV at Selected Primary Health Facilities of South-Western Uganda: A Qualitative Study. HIV/AIDS - Research and Palliative Care. 2021 Dec 31;13:939–58. Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care. 2009 Jan 1;21(1):87–93. Augustinavicius JL, Baral SD, Murray SM, Jackman K, Xue QL, Sanchez TH, et al. Characterizing Cross-Culturally Relevant Metrics of Stigma Among Men Who Have Sex With Men Across 8 Sub-Saharan African Countries and the United States. Am J Epidemiol. 2020 Jan 13;189(7):690–7. Tapera T, Willis N, Madzeke K, Napei T, Mawodzeke M, Chamoko S, et al. Effects of a Peer-Led Intervention on HIV Care Continuum Outcomes Among Contacts of Children, Adolescents, and Young Adults Living With HIV in Zimbabwe. Glob Health Sci Pract. 2019 Dec 23;7(4):575–84. World Health Organization. Integrating psychosocial interventions and support into HIV services for adolescents and young adults. 2023. Harper GW, Lemos D, Hosek SG. Stigma Reduction in Adolescents and Young Adults Newly Diagnosed with HIV: Findings from the Project ACCEPT Intervention. AIDS Patient Care STDS. 2014 Oct 1;28(10):543–54. UNAIDS. Evidence for eliminating HIV-related stigma and discrimination - Guidance for countries to implement effective programmes to eliminate HIV-related stigma and discrimination in six settings. 2020. French H, Greeff M, Watson MJ. Experiences of people living with HIV and people living close to them of a comprehensive HIV stigma reduction community intervention in an urban and a rural setting. Sahara J. 2014 Jan 1;11(1):105. 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Ocheret","email":"","orcid":"","institution":"UNAIDS","correspondingAuthor":false,"prefix":"","firstName":"Daria","middleName":"","lastName":"Ocheret","suffix":""},{"id":465342063,"identity":"c585fb46-d78e-4b24-b3a2-f15995e80961","order_by":15,"name":"Tatenda Makoni","email":"","orcid":"","institution":"Zimbabwe National Network of People Living with HIV/AIDS","correspondingAuthor":false,"prefix":"","firstName":"Tatenda","middleName":"","lastName":"Makoni","suffix":""},{"id":465342065,"identity":"ee815083-2c09-46b8-bd1f-bfdbe3634796","order_by":16,"name":"Tonderai Mwareka","email":"","orcid":"","institution":"Zimbabwe National Network of People Living with HIV/AIDS","correspondingAuthor":false,"prefix":"","firstName":"Tonderai","middleName":"","lastName":"Mwareka","suffix":""},{"id":465342067,"identity":"0c9e23f3-8bcf-4409-acc8-be60b6839a17","order_by":17,"name":"Stefan Baral","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Stefan","middleName":"","lastName":"Baral","suffix":""},{"id":465342073,"identity":"bd635658-3eb6-480e-85ff-fd035be70913","order_by":18,"name":"Katherine Rucinski","email":"","orcid":"","institution":"Johns Hopkins Bloomberg School of Public Health","correspondingAuthor":false,"prefix":"","firstName":"Katherine","middleName":"","lastName":"Rucinski","suffix":""}],"badges":[],"createdAt":"2025-05-08 00:23:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6615390/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6615390/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-025-25589-6","type":"published","date":"2025-11-22T15:58:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":96650138,"identity":"e5ee97a7-e89f-427a-847c-37177270a370","added_by":"auto","created_at":"2025-11-24 16:08:35","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1043117,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6615390/v1/2dd051df-a581-4260-a7e6-a85931e26a32.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"HIV Stigma and Treatment Interruptions among People Living with HIV in Zimbabwe: An Age-Stratified Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the context of Zimbabwe\u0026rsquo;s HIV epidemic, adolescents and young adults ages 15\u0026ndash;24 remain disproportionately affected; accounting for one-third of new infections in Zimbabwe despite comprising less than a fifth of the population.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Young people also face specific barriers when it comes to HIV testing, treatment access, and antiretroviral therapy (ART) adherence, with lower rates of utilization compared to their older counterparts.[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Among all people living with HIV in Zimbabwe, 87% of those who are receiving treatment have achieved viral suppression. However, only 45% of young people living with HIV are estimated to be virally suppressed.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eFor adolescents and young adults living with HIV, stigma remains a pervasive barrier to initiating and remaining engaged in HIV treatment.[\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] HIV-related stigma can manifest in different forms: internalized stigma, where individuals adopt negative beliefs about themselves related to their HIV status; anticipated stigma, the expectation of encountering prejudice or discrimination from others based on their HIV status; and enacted stigma, where individuals experience prejudice or discrimination from others because of their HIV status.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] For adolescents and young adults living with HIV, the effects of these stigmas are exacerbated by biological and psychosocial development [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and have been shown to impact mental health, ART adherence, and retention in care.[\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn Zimbabwe, previous studies have highlighted the specific challenges faced by youth living with HIV, including the complexities of navigating disclosure, sexual relationships, and discrimination while also transitioning into adulthood and encountering issues of acceptance, peer pressure, and the formation of personal identity.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] The fear of rejection or discrimination can lead to suboptimal adherence and disengagement in HIV care, which may be amplified during a life stage where interpersonal relationships play a critical role in providing support and boosting self-esteem.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] Moreover, older adolescents have a higher prevalence of loss to follow-up and virological failure compared to their younger counterparts, illustrating the challenges associated with transitioning to greater autonomy and independence in treatment management.[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] These additional health needs, alongside stigma and discrimination, have led to a higher burden of psychosocial and mental health challenges compared to peers living without HIV.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSustained ART adherence is crucial for the health and wellbeing of people living with HIV, but has remained a challenge for youth.[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Interruptions in treatment adherence can result in negative health impacts, including opportunistic infections and onward transmission to sexual partners.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Although numerous studies have demonstrated the link between HIV stigma and decreased ART adherence, few have explored this relationship in the context of young adults\u0026rsquo; experiences, perspectives, and needs.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] There is also a limited understanding of the extent to which the association between HIV stigma and treatment interruptions manifest differently for youth compared to older adults. In response, these analyses aim to address this gap by examining different manifestation of stigma \u0026ndash; both internalized and anticipated \u0026ndash; and their associations with treatment interruptions among young and older adults in Zimbabwe.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and population\u003c/h2\u003e \u003cp\u003eCross-sectional data collected from the People Living with HIV (PLHIV) Stigma Index 2.0 study in Zimbabwe in 2021 were used for these analyses. The PLHIV Stigma Index 2.0 is a research tool designed by and for people living with HIV and coordinated by an international partnership of the Global Network of People Living with HIV (GNP+), International Community of Women Living with HIV (ICW), and The Joint United Nations Programme on HIV/AIDS (UNAIDS). The Zimbabwe National Network of People Living with HIV (ZNNP+) led the implementation of the PLHIV Stigma Index 2.0 in Zimbabwe, gathering evidence on stigma and discrimination experienced by people living with HIV to inform research, HIV policy development, community mobilization efforts, evidence-based advocacy, and program implementation.[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] The Stigma Index study places individuals living with HIV at the core of the research process, enabling them to shape both data collection and analysis, including the analyses presented here.\u003c/p\u003e \u003cp\u003eIn Zimbabwe, the PLHIV Stigma Index 2.0 study was implemented over two months in 2021. Study development, design, and recruitment procedures have been previously described.[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] Briefly, the Stigma Index sampling approach is standardized across countries, with 75% of respondents recruited through venue-based sampling, and 25% recruited through limited chain referral sampling. The sampling procedure was adapted to align with the local context, relying on the expertise of implementing teams in Zimbabwe. The selected venues included health facilities, community spaces, and hotspots. Community-led organizations, including the Zimbabwe National Network of People Living with HIV (ZNNP+), Gays and Lesbians Association of Zimbabwe (GALZ), Rainbow Coalition Zimbabwe, and Trans and Intersex Rise in Zimbabwe, identified key populations such as men who have sex with men, sex workers, transgender individuals, and people who use drugs. The minimum sample size of 1,387 was calculated using the PLHIV Stigma Index 2.0 Sample Size Calculator [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], based on the prevalence of healthcare avoidance with a precision of 2.5% at a 95% confidence interval. All ten provinces of Zimbabwe were included. Eligibility criteria included informed written consent, age 18 or older, verbal and written communication ability in English, Shona, or Ndebele, aware of living with HIV for at least 12 months, and physically and mentally able to answer survey questions.\u003c/p\u003e \u003cp\u003eData were collected through interviewer-administered socio-behavioral surveys. Interviewers were people living with HIV recruited from Zimbabwean HIV networks and participated in translation of the questionnaire into Shona and Ndebele, and completed a three-day training on study implementation and interviewing techniques. During structured interviews, study participants were presented with the Stigma Index 2.0 questionnaire verbally, and their responses were electronically recorded using handheld tablets.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOutcome\u003c/h2\u003e \u003cp\u003eThe primary outcome was a prior interruption in HIV treatment. This measure was derived from the question \u0026ldquo;Have you ever interrupted or stopped your HIV treatment?\u0026rdquo;, which was asked only of individuals who reported currently taking or having previously taken HIV treatment. Responses were dichotomized into ever stopping treatment (answering \u0026ldquo;yes\u0026rdquo;) and never stopping treatment (answering \u0026ldquo;no\u0026rdquo;). Those who responded with \u0026ldquo;I don\u0026rsquo;t know/can\u0026rsquo;t remember\u0026rdquo; (2.1%, 29/1376) were excluded from regression models.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eExposure\u003c/h3\u003e\n\u003cp\u003eInternalized and anticipated stigma were the primary exposures. Internalized stigma was measured through seven survey items. Four items asked participants to \u0026ldquo;agree\u0026rdquo; or \u0026ldquo;disagree\u0026rdquo; with the following statements: \u0026ldquo;Being HIV positive makes me feel dirty\u0026rdquo;, \u0026ldquo;I feel guilty that I am HIV positive\u0026rdquo;, \u0026ldquo;I am ashamed that I am HIV positive\u0026rdquo;, and \u0026ldquo;I sometimes feel worthless because I am HIV positive\u0026rdquo;. Answers were dichotomous; coded as 1 (\u0026ldquo;agreed\u0026rdquo;) or 0 (\u0026ldquo;disagreed\u0026rdquo;). The remaining three items asked whether HIV status had \u0026ldquo;positively affected, not affected, or negatively affected\u0026rdquo; the respondent\u0026rsquo;s self-confidence, self-respect, and ability to cope with stress. Answers were coded dichotomously as 1 (\u0026ldquo;negatively affected\u0026rdquo;) or 0 (\u0026ldquo;positively affected\u0026rdquo;, \u0026ldquo;not affected\u0026rdquo;, or \u0026ldquo;N/A\u0026rdquo;.) The internalized stigma score for each person was derived by summing the responses to these questions, resulting in a total score ranging from zero to seven where a higher score indicates a higher level of internalized stigma.\u003c/p\u003e \u003cp\u003eA similar process was followed to determine the anticipated stigma score for each respondent. The seven questions asked respondents to answer \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo; to the following statements: \u0026ldquo;I have chosen not to attend gatherings\u0026rdquo;, \u0026ldquo;I avoided going to a clinic or hospital when I needed to\u0026rdquo;, \u0026ldquo;I have chosen not to apply for job(s)\u0026rdquo;, \u0026ldquo;I have chosen not to seek social support\u0026rdquo;, \u0026ldquo;I have isolated myself from family and/or friends\u0026rdquo;, \u0026ldquo;I decided not to have sex\u0026rdquo;, and \u0026ldquo;I hide my HIV status from others\u0026rdquo;. Answers were dichotomous and coded as 1 (\u0026ldquo;yes\u0026rdquo;) or 0 (\u0026ldquo;no\u0026rdquo;). For each individual, a total score from zero to seven was obtained by adding each question response to determine the anticipated stigma score.\u003c/p\u003e \u003cp\u003eBased on the observed distribution of the internalized and anticipated stigma scores among the analytic sample, cut points were established to categorize the primary exposure variables.[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Both internalized and anticipated stigma measures were grouped into four categories which were conceptualized as: 'no stigma' (score of 0), 'low stigma' (scores 1\u0026ndash;2), 'moderate stigma' (scores 3\u0026ndash;4), and 'high stigma' (scores 5\u0026ndash;7). While there is no standardized approach for categorizing both internalized and anticipated stigma scores with adolescents and young adults, a similar data-driven approach was implemented with other stigma scales for youth in low- and middle-income settings.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eCovariates explored for inclusion in the multivariable model were age, gender, education, employment, racial minority status, and belonging to a social network/support group of PLHIV. Age was categorized as young adults (18\u0026ndash;24 years) and older adults (25 years and older). Highest level of education completed was categorized as no education/primary, secondary, and post-secondary education. Work was categorized as unemployed, part-time work, full-time work, or retired. Lastly, social support was dichotomized as being a member of a network/social support group (yes/no).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analyses\u003c/h2\u003e \u003cp\u003eAll analyses were restricted to respondents who were currently on or had previously initiated HIV treatment. Participants who had never initiated treatment were excluded, as they could not experience treatment interruptions, the primary outcome. Differences in characteristics were descriptively compared across young and older participants. A Pearson\u0026rsquo;s chi-square (χ\u0026sup2;) test was used to compare differences in proportions for categorical variables.\u003c/p\u003e \u003cp\u003eModified Poisson regression models fit with a robust variance estimator were used to estimate unadjusted and adjusted prevalence ratios (PR) and 95% confidence intervals (CI) for the association between each stigma measure and the outcome of ever stopping treatment.[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] Both internalized and anticipated stigma variables were treated as categorical exposures with four levels (\u0026ldquo;no\u0026rdquo;, \u0026ldquo;low\u0026rdquo;, \u0026ldquo;moderate\u0026rdquo;, and \u0026ldquo;high\u0026rdquo;). Adjusted analyses controlled for potential confounders identified \u003cem\u003ea priori\u003c/em\u003e using the minority stress model and a systematic literature review, including gender, education, employment, racial minority status, and membership in a social network or support group.(30) Multicollinearity among covariates in the full model was assessed using a threshold variance inflation factor (VIF) of 5.[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eWe stratified the study population by age (young adults and older adults) to assess age-related differences in the relationship between stigma and treatment interruption. To formally explore effect measure modification by age group, we fit models with an interaction term between each categorized stigma score and age group. To determine if effect modification was present, a likelihood ratio test and corresponding p value (alpha\u0026thinsp;=\u0026thinsp;0.05) was used to compare the main model with the model with the interaction term. Analyses were conducted using Stata 17 statistical software (Statacorp, College Station, Texas).[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Medical Research Council of Zimbabwe. Interviewers received informed consent from participants who received information sheets, details of the study and its objectives, and privacy and confidentiality of data.\u003c/p\u003e \u003cp\u003eAnalyses of secondary data was reviewed by Johns Hopkins Institutional Review Board and determined exempt from human subject research.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,400 participants were interviewed in the Zimbabwe PLHIV Stigma Index 2.0 study, of whom 1376 who ever initiated HIV treatment were included in descriptive analyses (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Among them, 12.8% (176/1376) were young adults aged 18\u0026ndash;24. The sample comprised of 54.2% female (746/1376), 39.8% male (547/1376), and 6% transgender (83/1376) respondents. Unemployment levels were significantly higher among young adults (85/176, 48.3%) compared to older adults (421/1200, 35.1%) (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Completing a higher level of education also varied with 67.6% (119/176) of young adults and 59.7% (716/1200) of older adults having completed at least secondary education (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Experiences of internalized stigma were reported by 56.3% (99/176) of young adults versus 41.7% (500/1200) of older adults (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and experiences of anticipated stigma were reported by 73.9% (130/176) of young adults versus 51.8% (621/1200) of older adults (p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of 1376 PLHIV who have ever initiated treatment in Zimbabwe, stratified by age\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eYoung adults (18\u0026ndash;24 years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eOlder adults (\u0026gt;\u0026thinsp;24 years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1376)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;176)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;1200)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e p-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex assigned at birth\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e55.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e50.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e678\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e56.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e43.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCis Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e746\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e659\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e54.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCis Male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e547\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e39.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransgender woman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransgender man\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRacial, Ethnic or Religious Minority\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e591\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e517\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e43.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo education/primary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e364\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e30.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e835\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e67.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e716\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e59.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWork\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e35.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart-time work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e387\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e32.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFull-time work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e357\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e29.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMember of Network/Support Group\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e74.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e135\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e76.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e74.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eInternalized Stigma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e289\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e21.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e191\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnticipated Stigma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e625\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e48.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e56.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e506\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e42.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e5.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong 1347 PLHIV who ever initiated ART, 20.9% (36/172) of young adults and 10.3% (121/1175) of older adults reported treatment interruptions. Across all age groups, respondents who reported low (adjusted prevalence ratio (aPR) 1.7, 95% confidence interval (CI) 1.2\u0026ndash;2.9), moderate (aPR 2.6, 95% CI 1.7\u0026ndash;3.9), and high (aPR 3.5, 95% CI 2.1\u0026ndash;5.9) levels of internalized stigma experienced a higher prevalence of treatment interruptions compared to those reporting no internalized stigma (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Similarly, increasing levels of anticipated stigma were each associated with a higher prevalence of treatment interruptions compared to no anticipated stigma. Individuals with low (aPR 2.2, 95% CI 1.5\u0026ndash;3.4), moderate (aPR 3.2, 95% CI 1.8\u0026ndash;5.7), and high (aPR 4.9, 95% CI 2.8\u0026ndash;8.7) levels of anticipated stigma had an increased prevalence of treatment interruption in comparison to those reporting no anticipated stigma (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePrevalence ratios for the association of internalized and anticipated stigma with ever stopping treatment\u003csup\u003ea\u003c/sup\u003e among PLHIV in Zimbabwe.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eaPR\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternalized stigma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.2\u0026ndash;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.7*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.1\u0026ndash;2.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1\u0026ndash;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.6***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.7\u0026ndash;3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.8***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9\u0026ndash;7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.5***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.1\u0026ndash;5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnticipated stigma\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.5***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.7\u0026ndash;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.2***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.5\u0026ndash;3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.3***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.5\u0026ndash;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.8\u0026ndash;5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.4***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.7\u0026ndash;11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.9***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.8\u0026ndash;8.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\u003cp\u003eAbbreviations: PR, prevalence ratio; CI, confidence interval.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eThose who responded \u0026ldquo;I don\u0026rsquo;t\u0026rsquo; know/can\u0026rsquo;t remember\u0026rdquo; to ever stopping treatment were excluded\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Adjusting for age, gender, education, employment, racial minority, and belonging to a social network/support group\u003c/p\u003e\n\u003cp\u003e*p\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e***p\u0026lt;0.001\u003c/p\u003e\u003cp\u003e\u0026nbsp;In age stratified analyses, adjusted prevalence ratios for ever stopping treatment showed no significant association with low, moderate, or high levels of internalized stigma among young adults (Table 3). In contrast among older adults, those with low (aPR 1.6, 95% CI 1.0-2.7), moderate (aPR 2.9, 95% CI 1.9-4.6), and high (aPR 3.7, 95% CI 2.0-6.8) levels of internalized stigma had significantly higher prevalence of treatment interruption compared to individuals reporting no internalized stigma. Regarding anticipated stigma, in both age groups, individuals with low levels of stigma experienced a higher prevalence of treatment interruptions compared to those reporting no anticipated stigma (young adults: aPR 3.1, 95% CI 0.90-10.5; older adults: aPR 2.1, 95% CI 1.4-3.3). The prevalence ratio increased with moderate (young adults: aPR 6.6, 95% CI 1.7-25.9; older adults: aPR 2.6, 95% CI 1.3-5.1) and high (young adults: aPR 8.6, 95% CI 1.8-41.9; older adults: aPR 4.4, 95% CI 2.3-8.3) levels of anticipated stigma, although precision was low.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u003cem\u003eTable 3\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e: Prevalence ratios for the association of internalized and anticipated stigma with ever stopping treatment\u003csup\u003ea\u003c/sup\u003e among PLHIV in Zimbabwe, stratified by young vs. older adult status.\u003c/em\u003e\u003cem\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"658\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 264px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYoung adults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" style=\"width: 270px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOlder adults\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eaPR\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eaPR\u003csup\u003eb\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInternalized stigma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.71-4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.66-4.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e1.8*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.1-3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.0-2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.75-4.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.64-3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e3.4***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.2-5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e2.9***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.9-4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.1*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.2-8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.98-7.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e4.8***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.7-8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e3.7***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.0-6.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnticipated stigma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.94-10.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e0.90-10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e2.3***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.5-3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e2.1**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.4-3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eModerate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e6.3**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.7-23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e6.6**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.7-25.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e3.4***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.7-6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e2.6**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.3-5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 124px;\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 60px;\"\u003e\n \u003cp\u003e8.8**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.0-39.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e8.6**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e1.8-41.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e6.0***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e3.3-10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003e4.4***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e2.3-8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: PR, prevalence ratio; CI, confidence interval.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u003c/sup\u003eThose who responded \u0026ldquo;I don\u0026rsquo;t\u0026rsquo; know/can\u0026rsquo;t remember\u0026rdquo; to ever stopping treatment were excluded\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Adjusting for age, gender, education, employment, racial minority, and belonging to a social network/support group\u003c/p\u003e\n\u003cp\u003e*p\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e**p\u0026lt;0.01\u003c/p\u003e\n\u003cp\u003e***p\u0026lt;0.001\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe likelihood ratio test showed insignificant interaction effects of age with internalized and anticipated stigma on treatment interruption with test statistics of 1.7 and 0.3, and p-values of 0.20 and 0.61 for internalized stigma and anticipated stigma, respectively. \u0026nbsp; \u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn these analyses of Zimbabwe\u0026rsquo;s PLHIV Stigma Index data, we found the prevalence of treatment interruptions is twice as high among young adults compared to older adults, and higher levels of internalized and anticipated stigma were associated with treatment interruptions among people living with HIV. Notably, the magnitude and precision of these associations varied between young and older adults living with HIV. To date, few studies have compared the relationship between diverse facets of HIV-related stigma on ART utilization across age groups. The age-stratified prevalence ratios presented here indicate a stronger association between elevated anticipated stigma levels and treatment interruptions in young adults in contrast to the association observed among older adults. Conversely, the association between heightened internalized stigma and increased prevalence of treatment interruptions is weaker among young adults in contrast to older adults. As youth living with HIV transition into greater independence and continue to discover and assert their own sexual identities, addressing these barriers to ensure sustained engagement in HIV treatment represents an urgent public health priority.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Internalized and anticipated stigma were associated with a higher prevalence of ever stopping HIV treatment, reinforcing the importance of multilevel interventions addressing stigmas to improve HIV care continuity for people living with HIV. The association between higher stigma levels and treatment interruptions aligns with previous research across diverse populations and socio-cultural contexts, highlighting the role of stigma in the HIV care continuum.[9] At the individual level, internalized stigma has been shown to influence treatment adherence through depression, decreased motivation and behavioural skills, and lowered self-esteem.[12\u0026ndash;14,33] At the interpersonal level, anticipated stigma has been observed to create a sense of fear of inadvertent disclosure or potential negative consequences of taking treatment, which can undermine self-efficacy and adherence.[16,33,34] The effects of internalized and anticipated stigma on treatment and health outcomes among people living with HIV highlight the need for mitigating stigma as means to improve both the quality and quantity of life among people living with HIV in Zimbabwe and beyond.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The assessment of effect measure modification did not reveal statistical differences in effect estimates by age; however, there were noticeable differences in the magnitude of each association across age strata. While heightened levels of internalized stigma were associated with treatment interruption among older adults, the same significant relationship was not observed among young adults. The \u0026apos;life course perspective\u0026apos; suggests that attitudes toward HIV formed in one\u0026apos;s formative years shape how individuals perceive their identity in relation to HIV.[35] Increased ART access and efforts by organizations, like ZNNP+ and GALZ, have helped normalize HIV as a medical condition over time, potentially explaining why internalized stigma affects young adults to a lesser degree than older adults.[12,36\u0026ndash;38] In contrast, studies in the United States show older gay, bisexual, and other men who have sex with men (MSM) living with HIV exhibit less internalized stigma, with internalized stigma predicting ART non-adherence in young MSM but not older MSM.[39,40] These differences likely stem from the unique challenges and dynamics experienced by each population and context. Understanding the nuanced age-related differences in treatment interruption in the context of Zimbabwe highlights the imperative to recognize young adults living with HIV as distinct from older adults living with HIV. This differentiation can enable the development of age-specific interventions tailored to the unique needs and challenges at various life stages.\u003c/p\u003e\n\u003cp\u003eThe findings from these analyses also suggest that the fear or expectation of discrimination and rejection from others may have a greater influence on treatment interruption than the internalization of negative social attitudes and beliefs. Previous research has demonstrated the impact of anticipated stigma on decreasing treatment adherence among young people living with HIV in Zimbabwe.[7,18,33] During \u0026lsquo;emerging adulthood,\u0026rsquo; a phase marked by identity development and social integration, young adults may be especially sensitive to peer judgment and acceptance.[12,41] This transitional period can be pivotal in shaping feelings of anticipated stigma, which has been shown to disrupt interpersonal relationships among people living with HIV, leading to a loss of social support and social disengagement.[42] Conversely, young adults living with HIV with strong bonds to family, friends, and neighbours are better equipped to overcome barriers to ART adherence.[43] The strong influence of anticipated stigma on treatment outcomes among young adults in this study suggest strategies should prioritize addressing anticipated stigma that actively engage with social networks and community dynamics to create supportive environments and challenge stigma at the interpersonal level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. First, we were unable to directly measure treatment adherence using methods such as pill counts or drug levels, as the relies on self-reported interruption or stopping of treatment. This question likely oversimplifies the complexities of treatment adherence by categorizing individuals as having interrupted treatment, regardless of frequency or duration of interruptions. However, we assumed those reporting interruptions were less likely to adhere than those who reported never interrupting treatment. Second, few standardized internalized and anticipated stigma scales exist, particularly for youth. However, we adapted an internalized stigma score and generated an anticipated stigma score capturing dimensions of anticipated stigma within different social contexts.[44,45] We used a data-driven approach to inform cut points of no, low, moderate, and high stigma rather than determining strata \u003cem\u003ea priori\u003c/em\u003e, which may not be directly comparable to other contexts or populations. Third, resulting prevalence ratios in stratified analyses exhibited wide 95% confidence intervals, likely due to the small sample size of young adults in this study, comprising only 172 individuals. Moreover, while we did observe statistical effect measure modification by age, it\u0026rsquo;s likely our sample was not sufficiently powered to detect these effects. Further investigation is warranted to better understand the dynamics of internalized and anticipated stigma on treatment adherence among young adults living with HIV. Lastly, the questions that determined the exposure and outcome were not timebound. The cross-sectional design of the study did not allow us to determine if experiencing internalized or anticipated stigma preceded treatment interruption within this sample. A longitudinal design and, or combined with, qualitative interviews and case studies could better facilitate examination of the temporal sequence and establish causal relationships between these variables.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e\u0026nbsp;Given the prevalence of HIV among youth that will transition into adulthood and out of pediatric care in Zimbabwe and Sub-Saharan Africa, research and interventions tailored specifically to the needs of young adults are critical.[46,47] In this study, we observed different relationships between internalized stigma and treatment interruptions among age groups, with young adults living with HIV who reported treatment interruptions to be more affected by anticipated stigma than internalized stigma. In response to our findings, a multifaceted approach to combat anticipated stigma among young adults living with HIV in Zimbabwe could be a powerful strategy to improve continuity of treatment. Ongoing efforts in Zimbabwe, led by ZNNP+, to specify ongoing stigma interventions have highlighted gaps in addressing attribute-specific and intersectional stigmas. These data highlight the potential impact of efforts to challenge stigma and discrimination at the interpersonal level to foster a more supportive network for young adults living with HIV.[48\u0026ndash;50] Additionally, recommendations within the upcoming Zimbabwe multi-sectoral response plan advocate for the prioritization of interventions that focus on internalized stigma. Our research suggests that future recommendations consider expanding on these guidelines to include a distinct focus on anticipated stigma, particularly among youth. Finally, we advocate for the focus on young adults, distinct from older adults, in both research and program implementation, ensuring that interventions are designed with the specific needs of young adults in mind. Recognizing younger people living with HIV and their unique developmental challenges and social contexts, will be pivotal in maximizing service engagement of young people as a means of improving individual and population-level health outcomes in Zimbabwe.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Medical Research Council of Zimbabwe (Approval number MRCZ/A/2739). Interviewers received informed consent from participants who received information sheets, details of the study and its objectives, and privacy and confidentiality of data in accordance with the Declaration of Helsinki. Analyses of secondary data was reviewed by Johns Hopkins Institutional Review Board and determined exempt from human subject research (IRB0007442).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded, in part, by the U.S. National Institute of Allergy and Infectious Diseases under award R01AI170249, and by the U.S. National Institute of Mental Health under awards K01MH129226, R01MH132150, and P30MH136919. The Stigma Index 2.0 was made possible with financial support from UNAIDS. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAuthor\u0026rsquo;s contributions\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.M. and T.Mw. led study implementation and data collection in Zimbabwe, in partnership with O.S., P.L., K.L., J.A., F.C., S.B., K.D., L.S., C.G., and D.M., who all contributed to the study\u0026apos;s conception, design, and data acquisition. V.C. performed data analysis and led manuscript writing. K.R., along with other colleagues G.T., A.R., C.L., H.M., and S.Ba., supported data analysis and critically reviewed the manuscript. All authors reviewed, revised, and approved the final version of the manuscript presented for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe wish to acknowledge the participants\u0026mdash;people living with HIV\u0026mdash;in Zimbabwe who generously shared their time and experiences. We are grateful to the data collection teams and community-led organizations in Zimbabwe that supported the implementation of the People Living with HIV Stigma Index 2.0.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAIDSinfo | UNAIDS [Internet]. [cited 2023 Aug 12]. Available from: https://aidsinfo.unaids.org/\u003c/li\u003e\n\u003cli\u003eZimbabwe National Statistics Agency and United Nations Populations Fund. 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Available from: https://www.stigmaindex.org/wp-content/uploads/2023/11/PLHIV-Stigma-Index-Global-Report-2023-2.pdf\u003c/li\u003e\n\u003cli\u003eGlobal Network of People Living with HIV (GNP+), International Community of Women Living with HIV (ICW), \u0026amp; Joint United Nations Programme on HIV/AIDS (UNAIDS). (2023). \u003cem\u003eThe People Living with HIV Stigma Index global findings report 2023\u003c/em\u003e. https://www.stigmaindex.org/wp-content/uploads/2023/11/PLHIV-Stigma-Index-Global-Report-2023-2.pdf\u003c/li\u003e\n\u003cli\u003eGlobal Network of People Living with HIV (GNP+). Sample Size Calculator [Internet]. Available from: https://www.stigmaindex.org/library/sample-size-calculator/\u003c/li\u003e\n\u003cli\u003eNugent C, Rosato M, Hughes L, Leavey G. Risk factors associated with experienced stigma among people diagnosed with mental ill-health: a cross-sectional study. Psychiatr Q. 2021 Jun 1;92(2):633\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eOke OO, Akinboro AO, Olanrewaju FO, Oke OA, Omololu AS. Assessment of HIV-related stigma and determinants among people living with HIV/AIDS in Abeokuta, Nigeria: A cross-sectional study. SAGE Open Med. 2019 Aug 8;7:2050312119869109. \u003c/li\u003e\n\u003cli\u003eGavan L, Hartog K, Koppenol-Gonzalez GV, Gronholm PC, Feddes AR, Kohrt BA, et al. Assessing stigma in low- and middle-income countries: A systematic review of scales used with children and adolescents. Social Science \u0026amp; Medicine. 2022 Aug 1;307:115121. \u003c/li\u003e\n\u003cli\u003eChen W, Qian L, Shi J, Franklin M. Comparing performance between log-binomial and robust Poisson regression models for estimating risk ratios under model misspecification. BMC Medical Research Methodology. 2018 Jun 22;18(1):63. \u003c/li\u003e\n\u003cli\u003eMeyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull. 2003 Sep;129(5):674\u0026ndash;97. \u003c/li\u003e\n\u003cli\u003eJames G, Witten D, Hastie T, Tibshirani R. An Introduction to Statistical Learning [Internet]. New York, NY: Springer; 2013 [cited 2024 Mar 5]. (Springer Texts in Statistics; vol. 103). Available from: http://link.springer.com/10.1007/978-1-4614-7138-7\u003c/li\u003e\n\u003cli\u003eStataCorp. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC; 2021. \u003c/li\u003e\n\u003cli\u003eMasa R, Zimba M, Tamta M, Zimba G, Zulu G. The association of perceived, internalized, and enacted HIV stigma with medication adherence, barriers to adherence, and mental health among young people living with HIV in Zambia. Stigma and Health. 20220804;7(4):443. \u003c/li\u003e\n\u003cli\u003eKalichman S, Mathews C, El-Krab R, Banas E, Kalichman M. Forgoing antiretroviral therapy to evade stigma among people living with HIV, Cape Town, South Africa. J Behav Med. 2021 Oct 1;44(5):653\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eCahill S, Valad\u0026eacute;z R. Growing Older With HIV/AIDS: New Public Health Challenges. Am J Public Health. 2013 Mar;103(3):e7\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Brien S, Broom A. HIV in Harare: The role and relevance of social stigma. African Journal of AIDS Research. 2014 Oct 2;13(4):339\u0026ndash;49. \u003c/li\u003e\n\u003cli\u003eHuman Dignity Trust. Human Dignity Trust. 2019 [cited 2023 Jun 27]. Zimbabwe. Available from: https://www.humandignitytrust.org./country-profile/zimbabwe/\u003c/li\u003e\n\u003cli\u003eGoddard K. A Fair Representation. Journal of Gay \u0026amp; Lesbian Social Services. 2004 Jan 1;16(1):75\u0026ndash;98. \u003c/li\u003e\n\u003cli\u003eBatchelder AW, Burgess C, Perlson J, O\u0026rsquo;Cleirigh C. 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Frontiers in Public Health [Internet]. 2023 [cited 2023 Jun 29];11. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2023.1188446\u003c/li\u003e\n\u003cli\u003eAjuna N, Tumusiime B, Amanya J, Awori S, Rukundo GZ, Asiimwe JB. Social Networks and Barriers to ART Adherence Among Young Adults (18\u0026ndash;24 years) Living with HIV at Selected Primary Health Facilities of South-Western Uganda: A Qualitative Study. HIV/AIDS - Research and Palliative Care. 2021 Dec 31;13:939\u0026ndash;58. \u003c/li\u003e\n\u003cli\u003eKalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care. 2009 Jan 1;21(1):87\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eAugustinavicius JL, Baral SD, Murray SM, Jackman K, Xue QL, Sanchez TH, et al. Characterizing Cross-Culturally Relevant Metrics of Stigma Among Men Who Have Sex With Men Across 8 Sub-Saharan African Countries and the United States. Am J Epidemiol. 2020 Jan 13;189(7):690\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eTapera T, Willis N, Madzeke K, Napei T, Mawodzeke M, Chamoko S, et al. Effects of a Peer-Led Intervention on HIV Care Continuum Outcomes Among Contacts of Children, Adolescents, and Young Adults Living With HIV in Zimbabwe. Glob Health Sci Pract. 2019 Dec 23;7(4):575\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Integrating psychosocial interventions and support into HIV services for adolescents and young adults. 2023. \u003c/li\u003e\n\u003cli\u003eHarper GW, Lemos D, Hosek SG. Stigma Reduction in Adolescents and Young Adults Newly Diagnosed with HIV: Findings from the Project ACCEPT Intervention. AIDS Patient Care STDS. 2014 Oct 1;28(10):543\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eUNAIDS. Evidence for eliminating HIV-related stigma and discrimination - Guidance for countries to implement effective programmes to eliminate HIV-related stigma and discrimination in six settings. 2020. \u003c/li\u003e\n\u003cli\u003eFrench H, Greeff M, Watson MJ. Experiences of people living with HIV and people living close to them of a comprehensive HIV stigma reduction community intervention in an urban and a rural setting. Sahara J. 2014 Jan 1;11(1):105. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"HIV stigma, HIV treatment, treatment interruption, young adult, HIV, Zimbabwe","lastPublishedDoi":"10.21203/rs.3.rs-6615390/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6615390/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eHIV stigma negatively impacts antiretroviral therapy (ART) adherence in adults, but this relationship remains underexplored within the context of early adulthood. We examined manifestations of stigma and their associations with ART interruptions among young (18\u0026ndash;24 years) and older (25\u0026thinsp;+\u0026thinsp;years) people living with HIV (PLHIV) in Zimbabwe.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis analysis utilized cross-sectional data from the 2021 PLHIV Stigma Index 2.0, implemented by the Zimbabwe National Network of PLHIV in partnership with Global Network of People Living with HIV, The International Community of Women Living with HIV, and UNAIDS. Treatment interruptions were defined as ever interrupting or stopping HIV treatment. Internalized and anticipated stigma scores were categorized as \u0026ldquo;no\u0026rdquo;, \u0026ldquo;low\u0026rdquo;, \u0026ldquo;moderate\u0026rdquo; and \u0026ldquo;high\u0026rdquo;. Modified Poisson regression models estimated associations between categorized stigma scores and treatment interruptions, with age-stratified analyses among young and older adults.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 1347 PLHIV who ever initiated ART, 20.9% (36/172) of young adults and 10.3% (121/1175) of older adults reported treatment interruptions. Increasing levels of internalized stigma were associated with higher prevalence of treatment interruptions compared to no stigma (low:adjusted prevalence ratio(aPR) 1.7, 95%CI 1.1\u0026ndash;2.6, moderate:aPR 2.6, 95%CI 1.7\u0026ndash;3.9, high:aPR 3.5, 95%CI 2.1\u0026ndash;5.9). Similar associations were observed with anticipated stigma (low:aPR 2.2, 95%CI 1.5\u0026ndash;3.4, moderate:aPR 3.2, 95%CI 1.8\u0026ndash;5.7, high:aPR 4.9, 95%CI 2.8\u0026ndash;8.7). Among young adults, anticipated stigma was more strongly associated with treatment interruptions compared to older adults, while internalized stigma showed a weaker association.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDifferent relationships observed between stigma and treatment interruption across age groups highlight the opportunity for tailored interventions for young adults. Addressing stigma at the interpersonal level may optimize treatment adherence and engagement in care during early adulthood.\u003c/p\u003e","manuscriptTitle":"HIV Stigma and Treatment Interruptions among People Living with HIV in Zimbabwe: An Age-Stratified Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-03 15:00:10","doi":"10.21203/rs.3.rs-6615390/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-18T20:36:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T22:31:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-07T20:40:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"132440813226932617240023452482068297399","date":"2025-06-03T20:25:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228464512935231010571477074929575610546","date":"2025-06-03T11:05:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-01T18:53:43+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-16T07:59:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-13T13:20:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-13T13:17:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-05-08T00:12:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8a303464-6e8f-4f9f-a2c0-e433c72adcc4","owner":[],"postedDate":"June 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-24T16:02:11+00:00","versionOfRecord":{"articleIdentity":"rs-6615390","link":"https://doi.org/10.1186/s12889-025-25589-6","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-11-22 15:58:03","publishedOnDateReadable":"November 22nd, 2025"},"versionCreatedAt":"2025-06-03 15:00:10","video":"","vorDoi":"10.1186/s12889-025-25589-6","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25589-6","workflowStages":[]},"version":"v1","identity":"rs-6615390","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6615390","identity":"rs-6615390","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}