Addiction | 2019
Commentary on Whittle et al. (2019): Food insecurity, substance use and women living with/or at risk for HIV—temporal relations and underlying mechanisms
Abstract
HIV is indeed a pandemic of the poor, especially among women. The associations between food insecurity, substance use and HIV infection are well established [1], and yet the underlying mechanisms of these associations are not well understood. Food insecurity and substance use both predict sexual risks for contracting HIV [2,3] and both predict poor treatment outcomes among those infected [4,5]. Food insecurity is often assumed to result from substance use, an assumption that is fueled by stereotypes of malnourished people with drug addictions. However, as Whittle et al. [6] report, the temporal association between food insecurity and substance use can run in the opposite direction, such that greater food insecurity predicts increased substance use. This important finding has implications for policies and interventions aimed at reducing the harms of substance use in the context of poverty [7]. As HIV is increasingly concentrated in areas of poverty, the interacting impacts of food insecurity and substance use will become central in efforts to advance HIV prevention and treatment. Further complicating the interplay between food insecurity, substance use and HIVare the social stigmas attached to all three conditions. Stigma, and the experience of shame that it brings, exerts powerful social forces that keep people from seeking services, requesting assistance and gaining social support. Despite decades of research, the underlying mechanisms of HIV-related stigmas are poorly understood [8]. Even less is known about the stigmatization of substance abuse [9], and there are very few studies of food insecurity stigma. Recent advances in HIV stigma research have brought conceptual clarity to a field that had been relying on theories dating back more than five decades [10]. For example, Turan et al. [11] have developed a framework that encompasses multiple dimensions of HIV stigma, including individual-level stigma (e.g. internalized stigma and anticipated stigma) and structural stigma (e.g. discrimination and social inequalities), that may stem from multiple sources, including family, informal social interactions and health-care providers. Turan et al. argue that stigma perceptions and a history of stigma experiences can carry forward to impede engagement and retention in health care. The power of this framework lies in its underlying mechanisms that explain the linkages between stigma and health, and it is apparent that these same mechanisms have relevance to intersecting stigmas of food insecurity and substance use. Earnshaw et al.’s HIV Stigma Framework [8] has also replaced dated notions about stigma by explicating the concepts of internalized, anticipated and enacted stigma. Importantly, the HIV Stigma Framework has yielded psychometrically sound measures derived from the model constructs [12]. Guided by theoretical and measurement advances, studies show that HIV-related stigmas complicate food insecurity and depression in people living with HIV [13] and that food insecurity, substance use and stigma play interactive roles in promoting HIV disease progression [14]. Furthermore, the associations and temporal relationships between food insecurity, substance use and HIV observed by Whittle et al. in women may not be the same as those observed in men. The gender–power differentials in sexual relationships may mean the ways in which substance use and food insecurity interact to increase sexual risks for HIV may differ for men and women [2,3]. Gender differences in food insecurity may also interact with known gender differences in HIV stigma. For example, studies find that African women appear more likely to endorse desires for social distancing away from people living with HIV as well as greater anticipated HIV stigma [15]. Studies that include both men and women are needed to understand the moderating role of gender in these relationships. Contemporary stigma research has extended beyond what were initially unidimensional approaches, separately examining food insecurity, substance use and HIV stigma. Current studies are more likely to take a multi-dimensional approach to stigma and consider its temporal, mediating and multi-level associations. The next generation of research will go beyond multi-dimensionality to consider the intersectionality of multiple stigmas on multiple outcomes. Intersectional stigmas are the simultaneous co-occurrence of interacting stigmatized conditions that can have synergistic effects [16,17]. Recent intersectional stigma research, for example, has shown that internalized HIV stigma interacts with internalized substance use stigma to complicate depression, which itself is stigmatized [18]. Better understanding of the intersectionality of HIV, food insecurity and substance use stigmas will help advance viable effective interventions.