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This study tested a theoretical model of multi\u2010level risk pathways to internalized HIV stigma among South African ALHIV.<\/jats:p><jats:p><jats:bold>Methods<\/jats:bold>: From 2013 to 2015, a survey using <jats:bold>t<\/jats:bold>otal population sampling of ALHIV who had ever initiated anti\u2010retroviral treatment (ART) in 53 public health facilities in the Eastern Cape, South Africa was conducted. Community\u2010tracing ensured inclusion of ALHIV who were defaulting from ART or lost to follow\u2010up. 90.1% of eligible ALHIV were interviewed (<jats:italic>n<\/jats:italic> = 1060, 55% female, mean age = 13.8, 21% living in rural locations). HIV stigma mechanisms (internalized, enacted, and anticipated), HIV\u2010related disability, violence victimization (physical, emotional, sexual abuse, bullying victimization) were assessed using well\u2010validated self\u2010report measures. Structural equation modelling was used to test a theoretically informed model of risk pathways from HIV\u2010related disability to internalized HIV stigma. The model controlled for age, gender and urban\/rural address.<\/jats:p><jats:p><jats:bold>Results<\/jats:bold>: Prevalence of internalized HIV stigma was 26.5%. As hypothesized, significant associations between internalized stigma and anticipated stigma, as well as depression were obtained. Unexpectedly, HIV\u2010related disability, victimization, and enacted stigma were not directly associated with internalized stigma. Instead significant pathways were identified via anticipated HIV stigma and depression. The model fitted the data well (RMSEA = .023; CFI = .94; TLI = .95; WRMR = 1.070).<\/jats:p><jats:p><jats:bold>Conclusions<\/jats:bold>: These findings highlight the complicated nature of internalized HIV stigma. Whilst it is seemingly a psychological process, indirect pathways suggest multi\u2010level mechanisms leading to internalized HIV stigma. Findings suggest that protection from violence within homes, communities and schools may interrupt risk pathways from HIV\u2010related health problems to psychological distress and internalized HIV stigma. This highlights the potential for interventions that do not explicitly target adolescents living with HIV but are sensitive to their needs.<\/jats:p>","DOI":"10.7448\/ias.20.1.21771","type":"journal-article","created":{"date-parts":[[2017,8,18]],"date-time":"2017-08-18T00:10:02Z","timestamp":1503015002000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":98,"title":["HIV, violence, blame and shame: pathways of risk to internalized HIV stigma among South African adolescents living with HIV"],"prefix":"10.1002","volume":"20","author":[{"given":"Marija","family":"Pantelic","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mark","family":"Boyes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucie","family":"Cluver","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Franziska","family":"Meinck","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2017,8,21]]},"reference":[{"key":"e_1_2_12_2_1","first-page":"S144","volume-title":"J Acquir Immune Defic Syndr [Internet]","author":"Idele P","year":"2014"},{"key":"e_1_2_12_3_1","volume-title":"Health for the world's adolescents.","author":"World Health Organisation (WHO).","year":"2014"},{"key":"e_1_2_12_4_1","volume-title":"For every child, end AIDS: seventh stocktaking report.","author":"The United Nations Children's Fund (UNICEF).","year":"2016"},{"key":"e_1_2_12_5_1","doi-asserted-by":"publisher","DOI":"10.1080\/17437199.2014.996243"},{"key":"e_1_2_12_6_1","doi-asserted-by":"publisher","DOI":"10.1086\/507680"},{"key":"e_1_2_12_7_1","doi-asserted-by":"publisher","DOI":"10.1097\/QAI.0b013e31819675e9"},{"key":"e_1_2_12_8_1","doi-asserted-by":"publisher","DOI":"10.1097\/QAD.0b013e3283437c2b"},{"key":"e_1_2_12_9_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10461-009-9593-3"},{"key":"e_1_2_12_10_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10461-013-0437-9"},{"key":"e_1_2_12_11_1","doi-asserted-by":"publisher","DOI":"10.1080\/09540120701245999"},{"key":"e_1_2_12_12_1","doi-asserted-by":"publisher","DOI":"10.1080\/09540120802032627"},{"key":"e_1_2_12_13_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2007.01.006"},{"key":"e_1_2_12_14_1","doi-asserted-by":"publisher","DOI":"10.1007\/978-94-007-6324-1_12"},{"key":"e_1_2_12_15_1","doi-asserted-by":"publisher","DOI":"10.7448\/IAS.16.3.18734"},{"key":"e_1_2_12_16_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2009.07.033"},{"key":"e_1_2_12_17_1","doi-asserted-by":"publisher","DOI":"10.1007\/s10964-014-0146-3"},{"key":"e_1_2_12_18_1","doi-asserted-by":"publisher","DOI":"10.4065\/mcp.2009.0583"},{"key":"e_1_2_12_19_1","doi-asserted-by":"publisher","DOI":"10.1177\/1524838010386812"},{"key":"e_1_2_12_20_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.cpr.2009.08.003"},{"key":"e_1_2_12_21_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pmed.1001349"},{"key":"e_1_2_12_22_1","doi-asserted-by":"publisher","DOI":"10.1590\/1678-7153.201427422"},{"key":"e_1_2_12_23_1","doi-asserted-by":"publisher","DOI":"10.1108\/17596591111132873"},{"key":"e_1_2_12_24_1","doi-asserted-by":"publisher","DOI":"10.1177\/1524838014523336"},{"key":"e_1_2_12_25_1","doi-asserted-by":"publisher","DOI":"10.2499\/0896297586CH10"},{"key":"e_1_2_12_26_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2005.07.006"},{"key":"e_1_2_12_27_1","volume-title":"AIDS doesn't come through being together: children's experiences of HIV and AIDS related stigma in Zambia 2002\u20102003.","author":"Clay S","year":"2003"},{"key":"e_1_2_12_28_1","volume-title":"The role of stigma and discrimination in increasing the vulnerability of children and youth infected with and affected by HIV\/AIDS.","author":"Strode A","year":"2001"},{"key":"e_1_2_12_29_1","volume-title":"A qualitative assessment of orphans and vulnerable children in two Zimbabwean districts.","author":"Mahati ST","year":"2006"},{"key":"e_1_2_12_30_1","unstructured":"PantelicM BoyesM CluverL ThabengM.\u201cThey Say HIV is a Punishment from God or from Ancestors\u201d: cross\u2010cultural adaptation and psychometric assessment of an HIV stigma scale for south african adolescents living with HIV (ALHIV\u2010SS).Child Indic Res [Internet].2016Nov 23. 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