Original Research Article
The Moderating Role of HIV Stigma on the
Relationship between Perceived Social Support
and Antiretroviral Therapy Adherence
Self-Efficacy among Adult PLHIV
in South Africa
Journal of the International
Association of Providers of AIDS Care
Volume 23: 1-10
© The Author(s) 2024
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/23259582241228743
journals.sagepub.com/home/jia
Muziwandile Qiniso Luthuli, BSW, MScoSci (Social Work)1
and Johannes John-Langba, MPH, MSW, PhD1
Abstract
Background: People living with human immune deficiency virus (PLHIV) grapple with distinct challenges, including HIV stigma which
affects their antiretroviral therapy (ART) adherence self-efficacy. This study investigates the interaction of HIV stigma and perceived
social support on ART adherence self-efficacy among adult PLHIV in South Africa. Methods: This study utilized a cross-sectional design
that involved 201 participants selected using time location sampling at a tertiary health facility in Durban. Results: HIV stigma was significantly and negatively associated with self-efficacy (β = −7.860, t = −4.654, p = .001), with variations across different stigma levels (β =
−5.844, t = −4.003, p = .001). Social support was significantly and positively associated with self-efficacy at lower HIV stigma levels (β =
7.440, t = 3.887, p = .001), in contrast to higher levels (β = −2.825, t = 1.400, p = .163). Conclusion: Social support significantly influences ART adherence self-efficacy, particularly at lower levels of HIV stigma, but the effect of support weakens as stigma intensifies.
Keywords
Adherence, antiretroviral therapy, HIV stigma, self-efficacy, social support, South Africa
Plain Language Summary
The relationship between perceived social support and antiretroviral therapy adherence self-efficacy among adult PLHIV
in South Africa: The influence of HIV stigma.
People living with HIV face unique challenges, such as HIV stigma, which impact their ability to adhere to antiretroviral therapy (ART).
This study examined how HIV stigma and perceived social support affect the ART adherence self-efficacy of adults living with HIV in
South Africa. This survey involved 201 participants who were selected by using time location sampling at a health facility in Durban,
South Africa. The study found that HIV stigma had a significant and negative impact on self-efficacy (β = −7.860, t = −4.654, p = .001),
with variations depending on the level of stigma (β = −5.844, t = −4.003, p = .001). On the other hand, social support had a significant
and positive impact on self-efficacy at lower levels of HIV stigma (β = 7.440, t = 3.887, p = .001), but this effect weakened at higher
levels of stigma (β = −2.825, t = 1.400, p = .163). Social support plays an important role in influencing self-efficacy, especially when HIV
stigma is lower. However, the significant impact of social support diminishes as HIV stigma becomes more intense.
Date received: 11 September 2023; revised: 15 December 2023; accepted: 6 January 2024.
1
Background
Globally in 2022, the burden of the human immune deficiency
virus (HIV) remained disproportionately high with an estimated
39.0 million people living with HIV (PLHIV) along with 1.3
million new infection cases that were reported.1 The upsurge in
Discipline of Social Work, School of Applied Human Sciences, University of
KwaZulu-Natal, Durban, South Africa
Corresponding Author:
Muziwandile Qiniso Luthuli, Discipline of Social Work, School of Applied
Human Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban
4000, South Africa.
Email: muziwandileluthuli8@gmail.com
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License
(https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission
provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
Journal of the International Association of Providers of AIDS Care
the number of PLHIV was alarming in the Sub-Saharan Africa
region, where about two-thirds of the global HIV burden
(25.6 million) and slightly over half (51%) of new HIV infections
(660,000) were recorded in this region.1 In addition to these challenges South Africa with a population of 60.6 million encountered its own shortfalls by reporting approximately 7.6 million
PLHIV in the year 2022, which translated into an HIV prevalence rate of 12.5%.1 Nevertheless, it is worth noting the progress
that was made in the management of the HIV pandemic in South
Africa, as 75% of those living with HIV (5.7 million) were on
antiretroviral therapy (ART) program, giving hope in the fight
against HIV/AIDS.1 Despite this substantial progress, the
country still grapples with major obstacles related to managing
the adverse outcomes of the HIV/AIDS pandemic. One of
the major obstacles is the lack of efficacy translating to
ART adherence.11 The comprehensive approach is required in
addressing these issues and it is therefore imperative to involve education and support for PLHIV to bolster their confidence in adhering
to ART.47
Self-efficacy, as proposed by Bandura in 1977, refers to the
belief that one can succeed in any situation or task, influencing
the outcome.2 Specifically, ART adherence self-efficacy represents a person’s belief in their ability to follow prescribed
ART,42 which is essential for achieving positive health outcomes and enabling individuals to take control of their own
well-being. Numerous studies have explored self-efficacy in
relation to ART adherence among individuals living with
HIV.3-7 Researchers have delved into various factors influencing individuals’ self-efficacy in adhering to ART. The literature
discusses factors such as social support,5 coping, alcohol and
drug use,7 self-esteem,9 HIV stigma,8 and personal beliefs.3
The debate within research revolves around how these factors
can either positively or negatively impact ART adherence selfefficacy. While individual factors encompass personal beliefs,
self-esteem, and attitudes toward ART, contextual factors
include but are not limited to social support, HIV stigma, and
other factors. However, there is still much to learn about how
these factors interact to impact ART adherence self-efficacy.
Moreover, studies have highlighted a positive relationship
between ART adherence self-efficacy and actual adherence behavior.6,10,45,46 For instance, a study conducted by Umar et al46 in
Malawi found that individuals with higher ART adherence selfefficacy were more likely to engage in adherence behaviors,
given their stronger belief in their capability to execute necessary
actions. This finding underscores the importance of enhancing
self-efficacy beliefs through tailored interventions. However,
much remains to be understood about how personal and contextual
factors interact to impact ART adherence self-efficacy in South
Africa. Particularly, the interplay between social support and
HIV stigma within the South African context requires further
exploration. As social support can play a critical role in improving
ART adherence self-efficacy, this study hypothesizes that there is a
positive relationship between perceived social support and ART
adherence self-efficacy among adult PLHIV.
The importance of understanding how social support influences ART adherence among HIV/AIDS patients has been
recognized by many researchers.12,13,16,18 Social support,
which
refers
to
the
resources,
assistance,
and
emotional connection that individuals receive from their social
networks during times of stress, adversity, or need, plays a
crucial role in this context.19-21 This support can take different
forms, including instrumental support, which involves tangible
aids or services; emotional support, providing empathy, understanding, and compassion; and informational support, offering
advice, guidance, and relevant information.19,20 On the other
hand, HIV stigma can be a major barrier to seeking and receiving
social support, which can lead to feelings of low self-efficacy in
individuals living with HIV.15 HIV stigma refers to the negative
attitudes, beliefs, and prejudices directed toward individuals
living with HIV/AIDS.22 It encompasses public, internalized,
and enacted stigma, each contributing to the complex challenges
faced by affected individuals.23,24 The HIV stigma significantly
affects the mental health and overall well-being of PLHIV,
leading to increased rates of low self-esteem, depression,
anxiety, and isolation.17,25,40 The fear of rejection and discrimination can prevent them from seeking support, exacerbating
their emotional distress.26 Thus, stigmatizing attitudes and discriminatory behaviors toward PLHIV may exacerbate the negative effects of HIV, thereby impacting the mental health,
self-esteem, and overall well-being of PLHIV.25 Social identity
theory provides a theoretical rationale for HIV stigma as a moderator by explaining how individuals’ identification with a stigmatized group affects their self-concept and emotional
responses.27
Moreover, the social cognitive theory posits that individuals’
beliefs about their capabilities to perform specific actions,29
such as adhering to ART regimen effectively, are influenced
by social support and external factors such as HIV
stigma.18,28 HIV stigma can create a hostile environment that
hampers the development of self-efficacy and positive selfconcept among PLHIV, even in the presence of social
support.30 Several studies have explored the role of HIV
stigma on various aspects of the lives of PLHIV.31,33,35,36
Among these studies, Shrestha et al31 conducted research
among 599 PLHIV in Nepal and identified HIV stigma (internalized) as a significant moderator impacting psychological
outcomes (coping strategies, quality of life) and social outcomes (perceived social support) in this population. Another
study by Li et al32 in China found that HIV stigma partially
mediated the relationship between self-efficacy and medication
adherence, and fully mediated the relationship between selfefficacy and quality of life. Additionally, a study conducted
in Thailand by Mireles et al33 revealed a significant positive
relationship between social support and ART adherence, indicating that higher levels of social support were associated
with optimal levels of ART adherence. Moreover, this study
also found a complex three-way interaction between depression, social support, and HIV-related stigma, which jointly
influenced ART adherence among Thai participants.
Despite, numerous studies exploring the role of HIV stigma
in affecting the overall well-being of PLHIV,34 there is a
notable lack of research investigating the complex interplay
Luthuli and John-Langba
between HIV stigma, perceived social support and ART adherence self-efficacy. While Shrestha et al31 emphasized the
importance of HIV stigma as a moderator affecting psychological and social outcomes, but further investigation is necessary
to understand the underlying pathways linking HIV stigma to
social support and ART adherence self-efficacy. On the same
hand, while Li et al32 found evidence of HIV stigma as a mediator in the relationship between self-efficacy and ART adherence and quality of life, there remains a dearth of research in
understanding the mechanisms through which HIV stigma
and social support interact to influence ART adherence selfefficacy. Therefore, in light of the preceding discussion, this
study hypothesizes that the positive relationship between perceived social support and ART adherence self-efficacy will be
negatively moderated by HIV stigma among adult PLHIV.
Additionally, Mireles et al33 found that the influence of
depression on ART adherence was moderated by both social
support and HIV stigma. These results warrant further investigation into how the influence of social support on ART adherence self-efficacy depends on the levels of HIV stigma. In the
context of the current study, HIV stigma acts as a potential moderator, that weakens the positive influence of social support on
ART adherence self-efficacy. Addressing HIV stigma becomes
crucial to ensure that social support fully serves its potential role
in enhancing self-efficacy and improving the overall well-being
of PLHIV. On the other hand, very few studies that
have examined the direct or indirect impact of social support on
ART adherence self-efficacy.15 For instance, a study by Tao
et al15 found a positive correlation between greater social
support and high levels of ART adherence self-efficacy.
Additionally, social support was found to play an indirect role in
influencing ART adherence in some studies. For example, Mi
et al14 in China reported that social support acted as a significant
mediator in the relationship between family disclosure and ART
adherence. Similarly, a recent study by Tao et al15 revealed a significant indirect effect of HIV-related stigma on HIV selfmanagement through social support. These results suggest that
social support can act as a mediator, serving as a protective
factor for ART adherence self-efficacy and actual ART adherence.
Indeed, existing research shows that social support predicts ART
adherence among PLHIV.12,13,16 However, there is dearth of
studies that investigate the direct impact of social support on
ART adherence self-efficacy and how the relationship
between these variables may be influenced by the levels of
HIV stigma among adult PLHIV in South Africa. Therefore,
this study further posits that the positive relationship between
perceived social support and ART adherence self-efficacy
among adult PLHIV will vary based on different levels of
HIV stigma.
3
acknowledging the significance of social context in knowledge
construction. According to this paradigm, knowledge is shaped
through human interactions within their surroundings.
The study utilized a nonprobability time location sampling
(TLS) method to recruit participants from an antiretroviral
(ARV) clinic situated in a tertiary hospital in Durban,
KwaZulu-Natal. The TLS is a valuable method for gathering
data on hard-to-reach populations, such as men who have sex
with men58 and PLHIV. This method involves selecting specific
locations where individuals of interest can be found and then sampling those who attend these locations during predetermined time
intervals.58,59 Therefore, TLS was a practical choice with the aim
to access populations with diverse and dynamic characteristics
given that the data collection occurred during the coronavirus
(COVID-19)-led lockdown. This approach allowed for the inclusion of individuals who may not be adequately represented in
the conventional sampling frames, thereby improving the external
validity of the study.58 While probabilistic methods are generally
preferred for their randomness and potential to produce representative samples, the nonrandom TLS was implemented to address
pitfalls related to sample representation, inclusivity, and accessibility.58 The determination of location was established upon the principle of “social viability,”59 which ensures the presence of a
satisfactory number of individuals from the target population at
the designated venue, and provides insights into the optimal
time periods for engaging with this population.
The first step involved determining a key location, which
was a tertiary health facility in Durban, for participant
recruitment process. The second step focused on sampling
periods that were strategically chosen to collect comprehensive
and diverse data, given different time slots designated on
selected days of the week. For instance, the data collection
process involved the allocation of specific time intervals onto
four weekdays, considering the operating hours of the health
facility. However, the allocation was done randomly, resulting
in the following intervals: Mondays (13:00 h-15 00), Tuesdays
(09:00-11:00), Wednesdays (11:00-13:00), and Thursdays
(07:00-9:00). During these time intervals, potential participants
were approached and selected nonrandomly with a purpose to
reach individuals who may not be sufficiently represented in traditional sampling frames. This approach helpe
d to improve external validity, maximize access to marginalized
and stigmatized groups,59 and reach the target number of participants. This approach also allowed us to gather a variety of
responses from participants residing in different urban communities in Durban. Eligible participants meeting the inclusion criteria
were selected voluntarily and encompassed PLHIV aged 18 years
or older, enrolled in an ART program, and residing in suburban
and township communities of Durban, South Africa. Data collection took place between June and October 2020, coinciding with
the COVID-19 pandemic in South Africa.
Methods
Study Design, Population, and Sampling
Sample Size Determination
Utilizing a cross-sectional quantitative research design, this
study was grounded in the postpositivistic paradigm,
The determination of the sample size took a careful
consideration of both financial resources and statistical
4
Journal of the International Association of Providers of AIDS Care
reliability while ensuring the feasibility of the study. To determine the minimum required sample size, the researchers applied
the formula proposed by Lemeshow et al48 this formula is wellregarded for its ability to ensure the balance between costeffectiveness and the reliability of statistical inferences.
a
p (1 − p)
Z2 1 −
(1.96)2 0.144 x 0.856
2
=
S=
d2
0.052
= 189.41 = 189
Table 1. Demographic Information of Study Participants (N = 201).
The margin of error (precision) d2 was established at ±5% in
this context. This means that the sample mean will deviate
from the true population mean by ±5% in terms of the error
in the sample statistics. In addition, the parameter 1 − a2
denotes a desired confidence level of 95%, which represents a
critical value (z-value) of 1.96, indicating that the researchers
were 95% confident that the responses from the entire population will fall within the accepted precision. The estimated population proportion p (1 − p) was determined to be 14.4%
derived from preliminary findings of the pilot study50 and
was used to calculate the appropriate minimum sample size.
The parameter S of the formula represents the sample size.
The missing data is of utmost importance when determining
the sample size as it has a direct influence on the statistical
power and validity of the findings.49 To ensure the reliability
and accuracy of the results, a standard of 50% was used to determine the acceptability of missing data that has occurred either at
completely random, random, or nonrandom.49 For instance, the
number of 222 subjects participated in the study, exceeding the
estimated minimum required sample size of 189 subjects.
However, 21 subjects were excluded from the analysis due to
the presence of incomplete data in their questionnaires, surpassing the permissible threshold of less than 50% missing data.49
Data Collection Methods
As an integral component of the survey questionnaire, essential
sociodemographic information was gathered (Table 1). To
ensure unbiased translation, the nominated language experts
underwent a blind translation process, where both questionnaire
and informed consent were translated into IsiZulu from English
and then translate back from Zulu to English. Before engaging
in the survey, all participants who volunteered their involvement in the study provided a written consent. The questionnaire
itself required approximately 25 minutes to complete.
Measures
HIV-Stigma: Short Version of HIV Stigma Scale. The Short Version
of the HIV stigma scale (HSS-12) was employed in this study to
evaluate the presence of HIV stigma, comprising four distinct
subscales: internalized stigma (consisting of three items), disclosure concerns (with three items), concerns about public
attitudes (also with three items), and negative self-image
(comprising three items).43 Each subscale item exemplifies
Demographic variables
Frequency
Percentage
(%)
Age
18-24 years
25-35 years
36-45 years
46-55 years
56-65 years
66 years and above
Mean age: 39.28 years
(SD = 12.115)
30
37
61
40
16
17
14.9
18.4
30.3
19.9
8.0
8.5
Sex
Male
Female
58
142
29.0
71.0
Marital status
Never married
Married
Divorced
Widowed
Separated
147
36
6
5
4
74.2
18.2
3.0
2.5
2.0
Highest level of
education
No formal education
16
8.0
Primary education
Secondary education
Tertiary education
36
97
47
17.9
48.3
23.4
Unemployed
132
65.7
Formally employed
Self-employed
Retired
41
24
2
20.4
11.9
1.0
Employment
status
different aspects of HIV stigma. For instance, an item representing internalized stigma is, “People I care about stopped
calling after learning I have HIV,” while a disclosure concerns item is phrased as “I work hard to keep my HIV a
secret.” Additionally, concerns about public attitudes are
reflected in an item stating, “People with HIV are treated
like outcasts,” and negative self-image is represented by
the item “I feel I’m not a good person as others because I
have HIV.”
Participants responded to these items on a 4-point Likert
scale, ranging from 1 (strongly disagree) to 4 (strongly
agree).43 The total score range for each subscale of the
HSS-12 is 3 to 12, with scoring determined by summing the
ratings of the individual items of each subscale.43
Additionally, individual scores were added together across all
subscales to obtain the total HSS-12 score for each participant.
Afterward, the median score for the total HSS-12 scores across
the entire group of participants was calculated. The possible
scores for the overall HSS-12 ranged from 12 to 48. The
median score was used to perform a median split on the total
HSS-12 scores. Therefore, participants with scores higher
than the median were classified as having experienced high
levels of HIV stigma, while those with scores lower than the
median were identified as having experienced low levels of
Luthuli and John-Langba
HIV stigma. Previous studies have shown a good to excellent
internal consistency for the HSS-12, with Cronbach’s alpha
coefficients ranging from .75 to .96.43,51-54 In the context of
the present study, the internal reliability for the HSS-12 was
established, showing Cronbach’s alpha coefficients of .87
which indicates an excellent internal consistency.
Social Support: The Multidimensional Scale of Perceived Social
Support. The Multidimensional Scale of Perceived Social
Support (MSPSS-12) was employed as an instrument to
assess the perceived social support, comprising 12 self-report
items. The MSPSS segregates these items into three distinct
factor groups, corresponding to the sources of perceived
social support: family (four items), friends (four items), and significant others (four items).44 Respondents rated their agreement with each item on a 7-point Likert scale, ranging from 1
(very strongly disagree) to 7 (very strongly agree), where
higher scores across all dimensions signified greater levels
of perceived social support. The MSPSS-12 has demonstrated excellent internal consistency, with reported overall
Cronbach’s alpha coefficients ranging from .80 to
.95.44,55,56 In the current study, Cronbach’s alpha coefficient
was calculated to be .85, indicating a high level of internal
consistency.
ART Adherence Self-Efficacy: HIV Adherence Self-Efficacy Scale.
The assessment of ART adherence self-efficacy was carried
out using the HIV adherence self-efficacy (HIV-ASES-12)
scale, comprising 12 self-report items.42 These items are measured on a 4-point Likert scale, ranging from 0 (indicating no
confidence) to 3 (representing complete confidence), with
higher scores denoting high levels of ART adherence selfefficacy. Johnson et al42 originally demonstrated the scale’s
strong internal reliability by reporting a robust coefficient of
.90. In the present study, our analysis yielded a slightly lower
but still favorable Cronbach’s alpha of .88. An illustrative
item from the HIV-ASES scale reads as follows: “How confident have you been in the past month that you can adhere to
your treatment plan even when side effects begin to interfere
with daily activities?.”42 Respondents had to select one of the
four response options for an individual item: 0 (not at all confident), 1 (moderately confident), 2 (confident), or 3 (totally confident) based on their level of self-efficacy in handling these
specific situations.42
Statistical Analyses
A normality test was conducted for all continuous variables,
while frequencies and percentages were reported for categorical
variables. The association between HIV stigma, perceived
social support, and ART adherence self-efficacy was examined
using the Pearson correlation test. Furthermore, tolerance and
variance inflation factor (VIF)57 tests were performed to identify any collinearity issues among predictor variables. The
VIF values were all less than 5, indicating less issues of multicollinearity among predictor variables which was indicative of
5
no further corrective measures needed to be applied (Perceived
Social Support, Tolerance = .701, VIF = 1.426; HIV stigma,
Tolerance = .546, VIF = 1.830; HIV Stigma × Perceived
Social Support, Tolerance = .731, VIF = 1.368). The simultaneous multiple regression was performed, and moderation analysis was conducted using Statistical Package for the Social
Sciences (SPSS) Version 27 to test the moderation effect of
HIV stigma on perceived social support and ART adherence
self-efficacy. A significance level of p < .05 was used to determine statistical significance.
Ethical Approval and Informed Consent
Ethical clearance was obtained from the Institutional review
board of the University of KwaZulu-Natal (approval number:
HSSREC/00000607/2019). A formal support letter was produced and sent to the designated health facility namely King
Edward VIII tertiary Hospital. All patients provided written
informed consent prior to their enrollment in the study. The
consent included a brief description of the study, the use of
the information to be collected, benefits and risks associated
with participation, and the confidentiality and handling of the
gathered data. The consent form was carefully composed
using plain and easily understandable language to ensure that
participants fully comprehended its contents. Furthermore, the
rights of the participants were duly respected throughout the
entire duration of the study.
Results
Table 1 depicts the sociodemographic characteristics of the
study participants. The study sample was predominanted by
females, consisting of (71.0%, n = 142), with a mean age of
39.28 years (SD = 12.115). Most of the study participants had
never been married (74.2%, n = 147), and a significant proportion had completed secondary school education (48.3%, n =
97). Pertaining to the employment status about two-thirds of
the sample (65.7%, n = 132) reported being unemployed
(Table 1).
The Person’s Correlation analysis supported the first hypothesis, revealing a significant and positive correlation between
perceived social support and ART adherence self-efficacy (r =
.267, p < .01). On the other hand, a significant and negative correlation was found between HIV stigma and ART adherence
self-efficacy (r = −.315, p < .01). Moreover, perceived social
Table 2. Correlations among Central Study Variables.
Variables
Self-efficacy
Social support
HIV stigma
Self-efficacy
Social support
HIV stigma
1
.267**
−.315**
.267**
1
−.545**
−.315**
−.545**
1
HIV, human immune deficiency virus.
**. p < .01 (two-tailed), *. p < .05 (two-tailed).
6
Journal of the International Association of Providers of AIDS Care
Table 3. Full Regression and Simple Slopes Models of HIV Stigma, Perceived Social Support, and ART Adherence Self-Efficacy.
Full regression model
Intercept
SS
Stigma
Stigma × SS
Simple slopes models
b
SE
t
p
33.463
2.307
−7.860
−5.844
1.245
1.491
1.689
1.460
26.873
1.548
−4.654
−4.003
.001
.123
.001
.001
b
Low HIV-stigma slope
Intercept
38.539
SS
7.440
High HIV-stigma slope
Intercept
22.822
SS
−2.825
Simple slopes difference
SE
t
p
1.943
1.914
19.830
3.887
.001
.001
2.448
2.017
9.322
−1.400
.001
.163
t
3.692
df
398
P
.001
ART, antiretroviral therapy; df, degrees of freedom; HIV, human immune deficiency virus, SE, standard error; SS, social support.
Figure 1. The specific paths of the association between perceived
social support, ART adherence self-efficacy, and moderating effect.
*p < .05.
ART, antiretroviral therapy.
support and HIV stigma demonstrated a significant and negative association (r = −0.545, p < .01) (Table 2).
The estimates from Table 3 show the results of the full regression model, examining the main effects and interaction between
HIV stigma and perceived social support on ART adherence selfefficacy. The perceived social support did not show a significant
association with ART adherence self-efficacy (β = 2.307, t =
1.54, p = .123), whereas HIV stigma was significantly associated
with ART adherence self-efficacy (β = −7.860, t = −4.654, p =
.001). Interestingly, the interaction term (HIV Stigma × perceived
social support) indicated that the relationship between perceived
social support and ART adherence self-efficacy varied by
levels of HIV stigma (β = −5.844, t = −4.003, p = .001).
In Table 3, we further examined the association between perceived social support and ART adherence self-efficacy based on
conditions of HIV stigma using estimated simple slope models
and the theoretical moderation model shown in Figure 1. The
results revealed a significant relationship between perceived
social support and ART adherence self-efficacy at lower
levels of HIV stigma (β = 7.440, t = 3.887, p = .001).
However, at high levels of HIV stigma, perceived social
support was not significantly influencing ART adherence selfefficacy (β = −2.825, t = 1.400, p = .163). The test for differences
between the simple slopes confirmed a statistically significant
difference (t = 3.692, p = .001).
To visualize these findings, Figure 2 presents the plotted
simple slopes graph, regressing ART adherence self-efficacy
on perceived social support at high (+1SD) and low (−1SD)
levels of HIV stigma. The graph clearly illustrates that the positive relationship between perceived social support and ART
adherence self-efficacy was stronger at lower levels of HIV
stigma compared to higher levels, with the slope of the relationship for low HIV stigma being greater than for high HIV
stigma.
In summary, the analysis of the interaction term and the test
for differences in the simple slopes both indicated statistical significance, highlighting the moderating role of HIV stigma on
the relationship between perceived social support and ART
adherence self-efficacy.
Discussion
This study aimed to investigate the relationship between perceived social support and ART adherence self-efficacy and to
determine whether this relationship is moderated by HIV
stigma among adult PLHIV. The results from this study highlight the relationship between perceived social support, ART
adherence self-efficacy, and the moderating role of HIV stigma.
The bivariate results revealed the significant relationships
between perceived social support, ART adherence self-efficacy,
and HIV stigma. The perceived social support was positively
correlated with ART adherence self-efficacy, supporting our
first hypothesis. This result suggests that individuals with
higher perceived social support also had greater confidence in
adhering to their ART and this finding aligns with the results
found by Tao et al15 and Wang et al39 among PLHIV in
China. On the other hand, HIV stigma was found to be negatively correlated with ART adherence self-efficacy. This
result suggests that individuals with higher levels of HIV
stigma tend to have lower ART adherence self-efficacy. This
result was in line with that of Kamitani et al37 among Asian
PLHIV in California and Wang et al39 among Chinese
PLHIV. Additionally, perceived social support was found to
be negatively correlated with HIV stigma. This result was
Luthuli and John-Langba
7
Figure 2. Simple slopes plot graph.
suggestive of that individuals with higher perceived social
support would tend to have lower levels of HIV stigma. This
result was consistent with the recent study by Wang et al39 conducted across three provinces in China. These findings provided
a foundational understanding of the interplay between perceived social support, HIV stigma, and ART adherence selfefficacy among adult PLHIV.
The results from the full regression model confirmed the moderating role of HIV stigma on the relationship between perceived
social support and ART adherence self-efficacy and this was also
supportive of our second hypothesis. Additionally, the multiple
regression model displayed a negative direct effect of HIV
stigma on ART adherence self-efficacy which also implied that
higher levels of HIV stigma were associated with lower ART
adherence self-efficacy levels. This result was consistent with
the previous works that highlight the adverse effect of HIV
stigma on various facets of HIV care for PLHIV.30,31,38,39,41 The
profound understanding of the influence of HIV stigma on an individual’s confidence to adhere to ART is crucial, essentially for the
formulation of interventions that aim to improve adherence behaviors and overall well-being of PLHIV. It is also noteworthy that
this study is the first to our knowledge to investigate the role of
HIV stigma as a moderator of the relationship between perceived
social support and ART adherence self-efficacy among adult
PLHIV in South Africa.
The study also hypothesized that the positive influence of perceived social support on ART adherence self-efficacy varies with
different levels of HIV stigma among adult PLHIV. The results
from the simple slope models confirmed this hypothesis, given
that at lower levels of HIV stigma, ART adherence self-efficacy
was influenced significantly by perceived social support. This
result suggests that social support may become crucial, essentially
in situations where individuals are experiencing less HIV stigma.
On the contrary, the simple slope model indicated that at higher
HIV stigma levels, ART adherence self-efficacy was not significantly influenced by perceived social support. This finding suggests that HIV stigma overshadows the key role of social
support in fostering ART adherence self-efficacy among
adult PLHIV. These results contrast with that of the study done
by Wang et al39 where they found that perceived social support
had a significant impact on depression when HIV stigma was
high, suggesting that different populations may respond differently
on the basis of their perceptions of social support. Therefore, our
results have shed light on how HIV stigma moderates the relationship between perceived social support and ART adherence selfefficacy, and this underscores the need to address a stigma
related to HIV to improve confidence and adherence behaviors
of PLHIV.
These results have significant implications for interventions targeting HIV stigma, social support, and ART adherence selfefficacy among adult PLHIV. Healthcare providers and support
organizations should recognize the complexity of adherence behaviors and consider both social support and HIV stigma when developing interventions. The development of HIV stigma reduction
strategies and interventions aimed at enhancing social support networks are essential for an effective improvement of ART adherence
self-efficacy and treatment outcomes of PLHIV. Future research
should build upon these results and address the key limitations
highlighted by this study to advance our understanding of this
complex interplay between HIV stigma, perceived social support,
and ART adherence self-efficacy.
Limitations
This study makes a significant contribution by examining the
interplay between HIV stigma, perceived social support, and
8
Journal of the International Association of Providers of AIDS Care
ART adherence self-efficacy. However, several limitations warrant
a cautious interpretation of the results. Firstly, a cross-sectional
design of the study hinders the establishment of causal relationships between the variables under investigation. While significant
associations are observed, definitive cause-and-effect conclusions
cannot be drawn. Secondly, the reliance on self-reported measures
introduces subjectivity to the study, emanating from social
desirability, social norms, and recall bias which significantly and
collectively contribute to the lack of internal validity. Thirdly,
the use of nonprobability time location sampling may limit external validity by excluding individuals with immediate challenges
associated with ART adherence provided that the study recruited
participants from those attending follow-up appointments for
HIV treatment. These limitations underscore the need to interpret
the results with care and emphasize the necessity of future research
using longitudinal designs to explore temporal dynamics of adherence behaviour.
Despite the limitations, this study paves the way for future
investigations by highlighting HIV stigma as a potential psychosocial mechanism underlying the relationship between perceived social support and ART adherence self-efficacy. Thus,
researchers can expand their understanding of this intricate
relationship by building on these insights. Future studies
should explore additional confounding variables, such as sociodemographic factors, cultural variations, and mental health
aspects, that might have an influence between perceived social
support and ART adherence self-efficacy. Longitudinal designs
would be instrumental in untangling the temporal complexities
and potential causal links among these variables. Thus, this
study serves as a stepping stone in the ongoing quest to comprehend the multifaceted experiences of PLHIV and informs the
need for comprehensive and rigorous research to address the complexities of their lives.
Gratitude also to King Edward VIII Tertiary Hospital and
KwaZulu-Natal Department of Health for their unwavering support.
Conclusions
This study provided valuable insights into the psychosocial
dynamics experienced by adult PLHIV. The results revealed a positive relationship between perceived social support and ART
adherence self-efficacy. Higher levels of perceived social
support were significantly associated with higher ART adherence
self-efficacy in this population. In addition, HIV stigma moderated
the relationship between perceived social support and ART adherence self-efficacy. This result suggested that the impact of perceived social support on ART adherence self-efficacy was
influenced by the levels of HIV stigma experienced by PLHIV.
Notably, at lower levels of HIV stigma, perceived social support
demonstrated a stronger positive association with ART adherence
self-efficacy compared to higher levels. These findings underscore
the importance of tailored interventions addressing HIV stigma
and enhancing social support to improve ART adherence selfefficacy and overall well-being for PLHIV in South Africa.
Acknowledgments
Our heartfelt thanks go to the adult patients at Philani ARV Clinic,
King Edward VIII Tertiary Hospital, for their invaluable participation.
Authors’ Contributions
M.Q.L contributed to study conception, design, data acquisition,
analysis, manuscript drafting, and refinement of the final manuscript.
J.J.L contributed to study conception, design, data interpretation, manuscript review, and refinement of the final manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the
research, authorship, and/or publication of this article: This work was
supported by the National Research Foundation (Grant No.
MND190703452772).
ORCID iD
Muziwandile Qiniso Luthuli
https://orcid.org/0000-0002-4299-5558
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