Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women

HIV-Related Stigma Among Healthcare Providers in the Deep South

Stigma towards people living with HIV (PLWH) in healthcare settings is a barrier to optimal treatment. However, our understanding of attitudes towards PLWH from healthcare providers' perspective in the United States is limited and out-of-date. We assessed HIV-related stigma among healthcare staff in Alabama and Mississippi, using online questionnaires. Participants included 651 health workers (60 % White race; 83 % female). Multivariate regression suggests that several factors independently predict stigmatizing attitudes: Protestant compared to other religions (β = 0.129, p ≤ 0.05), White race compared to other races (β = 0.162, p ≤ 0.001), type of clinic (HIV/STI clinic: β = 0.112, p ≤ 0.01), availability of post-exposure prophylaxis (yes: β = -0.107, p ≤ 0.05), and perceptions of policy enforcement (policies not enforced: β = 0.058, p = p ≤ 0.05). These findings may assist providers wishing to improve the quality care for PLWH. Enforcement of policies prohibiting discrimination may be a useful strategy for reducing HIV-related stigma among healthcare workers.

The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature

This paper provides a review of the quantitative literature on HIV-related stigma and medication adherence, including: (1) synthesis of the empirical evidence linking stigma to adherence, (2) examination of proposed causal mechanisms of the stigma and adherence relationship, and (3) methodological critique and guidance for future research. We reviewed 38 studies reporting either cross-sectional or prospective analyses of the association of HIV-related stigma to medication adherence since the introduction of antiretroviral therapies (ART). Although there is substantial empirical evidence linking stigma to adherence difficulties, few studies provided data on psychosocial mechanisms that may account for this relationship. Proposed mechanisms include: (a) enhanced vulnerability to mental health difficulties, (b) reduction in self-efficacy, and (c) concerns about inadvertent disclosure of HIV status. Future research should strive to assess the multiple domains of stigma, use standardized measures of adherence, and include prospective analyses to test mediating variables.

HIV-related stigma and health-related quality of life among children living with HIV in Sweden

The relationship between HIV-related stigma and health-related quality of life (HRQoL) among children living with HIV infection is unknown. The objectives of this study were to describe HIV-related stigma and HRQoL among children with perinatal HIV living in Sweden, and to investigate the relationship between these two factors in the same infection group. In a cross-sectional nationwide survey, HIV-related stigma was measured with the 8-item HIV Stigma Scale for Children. HRQoL was measured with the 37-item DISABKIDS Chronic Generic Module. Structural equation modeling was used to explore the relationship between HIV-related stigma and HRQoL. Fifty-eight children participated, age 9-18 years (mean = 13.9). The HIV stigma general scale showed a mean score of 17.6 (SD = 5.0; possible range 8-32). DISABKIDS Chronic Generic Module general scale showed a mean score of 80.7 (SD = 14.1; possible range 0-100). HIV-related stigma was negatively associated with HRQoL (standardized β = -0.790, p = .017). The results indicate that children's concerns related to disclosure of their HIV infection seem to be common (i.e. 75% agreed) which, together with the negative association between ratings of HIV-relatively stigma and HRQoL, might indicate that disclosure concerns would be a relevant target for interventions to decrease HIV-related stigma and increase HRQoL.

Social Network Characteristics Moderate the Association Between Stigmatizing Attributions About HIV and Non-adherence Among Black Americans Living with HIV: a Longitudinal Assessment

BACKGROUND

Stigma may contribute to HIV-related disparities among HIV-positive Black Americans.

PURPOSE

We examined whether social network characteristics moderate stigma's effects.

METHODS

At baseline and 6 months post-baseline, 147 HIV-positive Black Americans on antiretroviral treatment completed egocentric social network assessments, from which we derived a structural social support capacity measure (i.e., ability to leverage support from the network, represented by the average interaction frequency between the participant and each alter). Stigma was operationalized with an indicator of whether any social network member had expressed stigmatizing attributions of blame or responsibility about HIV. Daily medication adherence was monitored electronically.

RESULTS

In a multivariate regression, baseline stigma was significantly related to decreased adherence over time. The association between stigma and non-adherence was attenuated among participants who increased the frequency of their interactions with alters over time.

CONCLUSIONS

Well-connected social networks have the potential to buffer the effects of stigma.

“Trust Me, It’s Different”: Experiences of Peer Case Management of Women Living with HIV in Ontario, Canada

In response to the dearth of research for delivering women-centred support to women living with HIV, the Women’s HIV Empowerment Through Life Tools for Health (wHEALTH) intervention was developed. This project was grounded in a community-based research framework and aimed to respond to barriers of women living with HIV in accessing appropriate and meaningful social supports. Participants described the benefits of the peer case management intervention including support, mentorship, flexibility in which the intervention was delivered, and the notion of “moving forward” in one’s journey with HIV. Through education, awareness, and advocacy, peer case managers are important partners in addressing HIV-related stigma, and ensuring a multi-level approach to providing care and support to women living with HIV.

Internalized HIV Stigma and Mindfulness: Associations With PTSD Symptom Severity in Trauma-Exposed Adults With HIV/AIDS

Rates of both traumatic event exposure and posttraumatic stress disorder (PTSD; 22%-54%) are disproportionately elevated among people living with HIV/AIDS (PLHA). Trauma and related psychopathology significantly affect quality of life and disease management in this patient population. The current study examined associations between internalized HIV stigma, mindfulness skills, and the severity of PTSD symptoms in trauma-exposed PLHA. Participants included 137 PLHA (14.6% female; Mage = 48.94, SD = 8.89) who reported experiencing on average, five (SD = 2.67) traumatic events; 34% met diagnostic criteria for PTSD. Results indicate that after controlling for sex, age, education, and number of traumatic events, internalized HIV stigma was positively related to overall PTSD symptom severity (β = .16, p < .05) and severity of re-experiencing (β = .19, p < .05) and hyper-arousal (β = .16, p = .05), but not avoidance, PTSD symptom clusters. Among the mindfulness facets measured, acting with awareness was uniquely negatively related to the overall severity of PTSD symptoms (β = -.25, p < .01) and the severity of re-experiencing (β = -.25, p < .05), avoidance (β = -.25, p < .05), and hyper-arousal (β = -.29, p < .01) PTSD symptom clusters. These effects were observed after accounting for covariates and shared variance with other mindfulness facets. Theoretically, the present findings suggest that internalized HIV stigma may serve as a vulnerability factor for the severity of certain PTSD symptoms, whereas acting with awareness may function as a protective or resiliency factor for the severity of PTSD symptoms. Implications for the treatment of trauma-exposed PLHA are discussed.

Social Media and HIV: A Systematic Review of Uses of Social Media in HIV Communication

BACKGROUND

Social media, including mobile technologies and social networking sites, are being used increasingly as part of human immunodeficiency virus (HIV) prevention and treatment efforts. As an important avenue for communication about HIV, social media use may continue to increase and become more widespread.

OBJECTIVE

The objective of this paper is to present a comprehensive systematic review of the current published literature on the design, users, benefits, and limitations of using social media to communicate about HIV prevention and treatment.

METHODS

This review paper used a systematic approach to survey all literature published before February 2014 using 7 electronic databases and a manual search. The inclusion criteria were (1) primary focus on communication/interaction about HIV/acquired immunodeficiency syndrome (AIDS), (2) discusses the use of social media to facilitate communication, (3) communication on the social media platform is between individuals or a group of individuals rather than the use of preset, automated responses from a platform, (4) published before February 19, 2014, and (5) all study designs.

RESULTS

The search identified 35 original research studies. Thirty studies had low or unclear risk of at least one of the bias items in the methodological quality assessment. Among the 8 social media platform types described, short message service text messaging was most commonly used. Platforms served multiple purposes including disseminating health information, conducting health promotion, sharing experiences, providing social support, and promoting medication adherence. Social media users were diverse in geographic location and race/ethnicity; studies commonly reported users aged 18-40 years and users with lower income. Although most studies did not specify whether use was anonymous, studies reported the importance of anonymity in social media use to communicate about HIV largely due to the stigma associated with HIV. The ability to share and receive information about HIV was the most commonly reported benefit of social media use and the most common challenges were related to technology. Measures of frequency of use, satisfaction, and effects of use varied across studies.

CONCLUSIONS

Using social media to bridge communication among a diverse range of users, in various geographic and social contexts, may be leveraged through pre-existing platforms and with attention to the roles of anonymity and confidentiality in communication about HIV prevention and treatment. More robust research is needed to determine the effects of social media use on various health and social outcomes related to HIV.

Understanding internalized HIV/AIDS-related stigmas in the Dominican Republic: a short report

HIV/AIDS-related stigmas can become internalized, resulting in declines in physical and mental health. Pathways to internalized HIV-related stigma (IS), characterized by persistently negative, self-abasing thoughts, are not well established among women living with HIV/AIDS (WLWHA) in the Dominican Republic (DR). Identifying factors involved in self-directed shaming and blaming is important, given the high HIV prevalence in the DR's most vulnerable populations. The present study sheds light on factors involved in negative and self-abasing thoughts in WLWHA in the DR by examining the relationship between depression, perceived HIV-related stigma from the community (PSC), perceived HIV-related stigma from family (PSF), and IS. The Internalized AIDS-Related Stigma Scale (IA-RSS), the Center for Epidemiologic Studies Short Depression Scale (CES-D 10), and an instrument designed to measure perceived HIV-related stigma from the community and family was administered to 233 WLWHA in Puerto Plata, DR. Data were analyzed using descriptive statistics and ordered multiple logistic regression. Results showed that depression (OR = 1.60; p < .05), PSC (OR = 3.68; p < .001), and PSF (OR = 1.60; p < .01) were positively associated with IS. These findings indicate that IS-reducing interventions should address HIV-related depression. Additionally, HIV-related treatment and care services should work with WLWHA to adopt healthier attitudes about how community members view people living with HIV/AIDS in the DR.

Trauma symptoms, internalized stigma, social support, and sexual risk behavior among HIV-positive gay and bisexual MSM who have sought sex partners online

Gay, bisexual, and other men who have sex with men (MSM) remain the highest risk group for HIV infection. One reason is the increased use of the Internet to meet potential sex partners, which is associated with greater sexual risk behavior. To date, few studies have investigated psychosocial predictors of sexual risk behavior among gay and bisexual men seeking sex partners online. The purpose of the current study was to test a conceptual model of the relationships between trauma symptoms indexed on the event of HIV diagnosis, internalized HIV stigma, and social support on sexual risk behavior among gay and bisexual MSM who seek sex partners online. A sample of 142 gay and bisexual MSM recruited on- and offline completed a comprehensive online assessment battery assessing the factors noted above. A number of associations emerged; most notably internalized HIV stigma mediated the relationship between trauma-related symptoms indexed on the event of HIV diagnosis and sexual risk behavior with HIV-negative and unknown serostatus sex partners. This suggests that gay and bisexual MSM who are in greater distress over their HIV diagnosis and who are more sensitive to HIV stigma engage in more HIV transmission risk behavior. As sexual risk environments expand with the increasing use of the Internet to connect with others for sex, it is important to understand the predictors of sexual risk behavior so that tailored interventions can promote sexual health for gay and bisexual MSM seeking sex online.

A Social-Ecological View of Barriers and Facilitators for HIV Treatment Adherence: Interviews with Puerto Rican HIV Patients

Purpose

To identify perceived barriers and facilitators for HAART adherence among people living with HIV/AIDS in Southern Puerto Rico using a Social Ecological framework.

Patients and Methods

Individual in-depths interviews were conducted with 12 HIV patients with a history of HAART non-adherence. Interviews were audio-taped and transcribed. Content analysis was performed for each transcribed interview by three independent coders using a codebook. Using Atlas TI, super-codes and families were generated to facilitate the categorization tree as well as grounded analyses and density estimates

Results

Most participants reported a monthly income of $500 or less (n = 7), a high school education level (n = 7), being unemployed (n = 9) and being recipients of government health insurance (n = 11). Three out of six women reported living alone with their children and most men informed living with their parents or other relatives (n = 4). For the grounded analyses, the top four sub-categories linked to high number of quotations were mental health barriers (G = 32) followed by treatment regimen (G = 28), health system (G = 24) and interpersonal relations (G = 16). The top four sub-categories linked to high number of codes are treatment regimen (D = 4), health status perception (D = 3), interpersonal relations (D = 3) and health system (D = 3).

Conclusion

The results of this study suggest the interconnection of HIV treatment adherence barriers at various system levels. Future studies on HIV treatment barriers should explore these interactions and investigate the possible synergistic effect on non-adherent behavior

Stigma, HIV and health: a qualitative synthesis

Background

HIV-related stigma continues to negatively impact the health and well-being of people living with HIV, with deleterious effects on their care, treatment and quality of life. A growing body of qualitative research has documented the relationship between HIV-related stigma and health. This review aims to synthesize qualitative evidence that explored the intersections of stigma and health for people with HIV.

Methods

A thematic summary was conducted that was guided by the qualitative metasummary technique developed by Sandelowski and Barraso. Literature searches yielded 8,622 references of which 55 qualitative studies were identified that illustrated HIV-related stigma in the context of health.

Results

The metasummary classified qualitative findings into three overarching categories: conceptualizing stigma which identified key dimensions of HIV-related stigma; experiencing stigma which highlighted experiences of stigma in the health context, and managing stigma which described ways in which stigma is avoided or addressed. To better illustrate these connections, the qualitative literature was summarized into the following themes: stigma within health care settings, the role of stigma in caring for one’s health, and strategies to address HIV-related stigma in the health context. A number of health care practices were identified – some rooted in institutional practices, others shaped by personal perceptions held by practitioners – that could be stigmatizing or discriminatory towards people with HIV. There existed interconnections between enacted stigma and felt stigma that influenced health care utilization, treatment adherence, and overall health and well-being of people with HIV. Intersectional stigma also emerged as instrumental in the stigma experiences of people living with HIV. A number of strategies to address stigma were identified including social support, education, self-efficacy, resilience activities, and advocacy.

Conclusion

This review of the qualitative evidence indicates that HIV-related stigma within health contexts is a broad social phenomenon that manifests within multiple social spheres, including health care environments. Findings from this review indicate that future stigma research should consider the social structures and societal practices – within and outside of health care environments – that perpetuate and reinforce stigma and discrimination towards people with HIV.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2197-0) contains supplementary material, which is available to authorized users.

Patient and provider priorities for self-reported domains of HIV clinical care

We sought to understand how HIV-infected patients, their providers, and HIV care researchers prioritize self-reported domains of clinical care. Participants rank-ordered two lists of domains. A modified Delphi process was used for providers and researchers. Approximately 25% of patients were interviewed to discuss rationale for rank order choices. List 1 included anger, anxiety, depression, fatigue, physical function, pain, and sleep disturbance. List 2 included alcohol abuse, cognitive function, HIV stigma, HIV and treatment symptoms, medication adherence, positive affect, sexual risk behavior, sexual function, social roles, spirituality/meaning of life, and substance abuse. Seventy-four providers, 80 HIV care researchers, and 66 patients participated. Patients ranked context-based domains, such as HIV stigma, more highly than providers, while health behaviors, such as drug or alcohol use, ranked lower. Patients described a need to address wider-context challenges such as HIV stigma in order to positively impact health behaviors. Divergent patient and provider priorities highlight the importance of incorporating views from all stakeholders and suggests the need for a care approach that more effectively addresses contextual barriers to adverse health behaviors.

Depressive Symptoms Mediate the Effect of HIV-Related Stigmatization on Medication Adherence Among HIV-Infected Men Who Have Sex with Men

This study tested the hypothesis that depressive symptoms would mediate the association of HIV-related stigma to medication adherence. We recruited HIV-infected men who have sex with men (MSM; N = 66; 66 % White, 23 % African-American) from an outpatient infectious disease clinic, and asked them to complete self-report measures. Mediational analyses showed that depressive symptoms fully mediated the association between HIV-related stigma and adherence. That is, stigma-related experiences were positively associated with depressive symptoms and negatively associated with adherence, and, in the final model, depressive symptoms remained a significant correlate of adherence while stigma did not. A test of the indirect effect of stigma on adherence through depressive symptoms was also significant (unstandardized b = -0.19; bootstrap 95 % CI -0.45 to -0.01). These results highlight the importance of treating depressive symptoms in interventions aiming to improve medication adherence among HIV-infected MSM.

Patterns and Correlates of Intimate Partner Violence to Women Living With HIV/AIDS in Osogbo, Southwest Nigeria

We assessed the prevalence and correlates of intimate partner violence (IPV) to women living with HIV/AIDS in an antiretroviral clinic in Nigeria. Three hundred sixty respondents were interviewed using a structured questionnaire. Sixty percent were married, of which 24% had disclosed HIV status to their partner. About a quarter (23.6%) had experienced IPV since HIV diagnosis. Types of violence experienced were physical violence (17%), emotional violence (21%), and sexual violence (2%). Predictors of IPV included having a younger aged partner, disclosing status, and partner's alcohol use (p = .001). Suggestions to prevent IPV include increasing public awareness and family counseling.

Effectiveness of Behavior Change Communications for Reducing Transmission Risks Among People Living with HIV in 6 Countries in Central America

This first region-wide study (N = 2,818) aims to estimate prevalence of HIV-related risks (sexual behavior, HIV disclosure, number of sex partners, violence) and factors associated with these risks as well as evaluate a behavior change communications program targeted to PLHIV in 6 countries in Central America. After 2 years, the program achieved moderate coverage, with 21 % of the sample reporting exposure to interpersonal communications (IPC) and 52 % to mass media program components. The odds of condom use, HIV disclosure, and participation in a self-help group increased by 1.4–1.8 times with exposure to mass media. Exposure to IPC increased odds of condom use by 2.7 and participation in self-help groups by 4.4 times. In addition, being in HIV care or taking ART was associated with condom use and HIV-status disclosure. About 30 % experienced physical or sexual violence, and those who did were 4 times less likely to use condoms. Findings suggest that behavioral interventions for PLHIV can reduce HIV-transmission risks and increase access to care.

Identifying HIV-Infected Women's Psychosocial Stressors: Findings from a Qualitative Study

To inform future psychosocial interventions for HIV-infected women, five focus groups were conducted with 29 HIV-infected women (72% African-American). Sessions were audio-recorded, transcribed, and coded by two raters. HIV-specific stressors included difficulties with serostatus disclosure, HIV medication adherence, and HIV-related discrimination. Stressors not directly linked to HIV were described as more concerning and included mental health or substance use problems, relationship challenges, caretaking for children or grandchildren, and financial difficulties. Participants suggested that interventions provide social support from other HIV-infected women, consistent case management and social work services, and forums to acquire additional information about HIV and treatment options.

Examining the Health Care Experiences of Women Living with Human Immunodeficiency Virus (HIV) and Perceived HIV-Related Stigma

INTRODUCTION

The increased incidence of human immunodeficiency virus (HIV) in women, particularly marginalized women, prompted research to examine women's health service experiences at a local outpatient clinic.

METHODS

A qualitative case study using semistructured interviews examined facilitators and barriers to health care services. Seventeen women living with HIV who accessed care at an outpatient HIV clinic in central west Ontario were interviewed. Thematic analysis was used to code health care experiences perceived as HIV-related stigma.

RESULTS

Women perceived HIV-related stigma when health care providers lacked basic HIV knowledge and failed to uphold the ethical principles of patient-provider relationships, resulting in women's disengagement from health care.

CONCLUSIONS

We propose a community-based participatory research framework to reform health care educational curriculum toward a culture of health care safety that is inclusive of people living with HIV.

Associations of stigma with negative health outcomes for people living with HIV in the Gambia: implications for key populations

BACKGROUND

The HIV epidemic in the Gambia is concentrated among stigmatized key populations. This study explores the relationship between 3 types of HIV-related stigma and 3 health outcomes among people living with HIV (PLHIV) in the Gambia.

METHODS

Three hundred seventeen PLHIV from PLHIV support groups in the Gambia were surveyed using the PLHIV Stigma Index.

RESULTS

Enacted stigma in health care settings was significantly associated with avoiding or delaying seeking care [adjusted odds ratio (aOR) = 3.03, 95% confidence interval (CI) = 1.24 to 7.89]; enacted stigma in the household or community (aOR = 1.21, 95% CI = 0.98 to 1.49) and internal stigma (aOR = 1.47, 95% CI = 0.96 to 2.22) were marginally associated. Enacted stigma in health care settings was significantly associated with non-use of antiretroviral therapy (aOR = 0.52, 95% CI = 0.31 to 0.88), whereas internal stigma and enacted stigma in the household or community were not. Enacted stigma in the household or community (aOR = 0.75, 95% CI = 0.64 to 0.87) and internal stigma (aOR = 0.69, 95% CI = 0.50 to 0.93) were significantly associated with poorer self-reported health status, whereas enacted stigma in health care settings was not.

CONCLUSIONS

PLHIV in the Gambia face stigma regardless of identity as members of key populations, who may face dual stigma. Stigma mitigation represents a potentially important component of a comprehensive package of services to improve the HIV care continuum in the Gambia. Targeted interventions that address stigma with health care workers could facilitate antiretroviral therapy use and timely care seeking for PLHIV. Interventions to address internal stigma and enacted stigma in the household and community may yield additional dividends for the overall health of PLHIV. Examining only 1 domain of stigma may not be sufficient to understand the effect of stigma on a specific health outcome.

Impact of age on retention in care and viral suppression

BACKGROUND

Retention in care is important for all HIV-infected persons and is strongly associated with initiation of antiretroviral therapy and viral suppression. However, it is unclear how retention in care and age interact to affect viral suppression. We evaluated whether the association between retention and viral suppression differed by age at entry into care.

METHODS

Cross-sectional analysis (2006-2010) involving 17,044 HIV-infected adults in 14 clinical cohorts across the United States and Canada. Patients contributed 1 year of data during their first full-calendar year of clinical observation. Poisson regression examined associations between retention measures [US National HIV/AIDS Strategy (NHAS), US Department of Health and Human Services (DHHS), 6-month gap, and 3-month visit constancy] and viral suppression (HIV RNA ≤200 copies/mL) by age group: 18-29 years, 30-39 years, 40-49 years, 50-59 years, and 60 years or older.

RESULTS

Overall, 89% of patients were retained in care using the NHAS measure, 74% with the DHHS indicator, 85% did not have a 6-month gap, and 62% had visits in 3-4 quarters of the year; 54% achieved viral suppression. For each retention measure, the association with viral suppression was significant for only the younger age groups (18-29 and 30-39 years): 18-29 years [adjusted prevalence ratio (APR) = 1.33, 95% confidence interval (CI): 1.03 to 1.70]; 30-39 years (APR = 1.23, 95% CI: 1.01 to 1.49); 40-49 years (APR = 1.06, 95% CI: 0.90 to 1.22); 50-59 (APR = 0.92, 95% CI: 0.75 to 1.13); ≥60 years (APR = 0.99, 95% CI: 0.63 to 1.56) using the NHAS measure as a representative example.

CONCLUSIONS

These results have important implications for improving viral control among younger adults, emphasizing the crucial role retention in care plays in supporting viral suppression in this population.

HIV stigma and disclosure experiences of people living with HIV in an urban and a rural setting

Human immunodeficiency virus (HIV) remains a highly stigmatised condition for people living with HIV (PLWH) and people living close to them (PLC) globally. The research objectives for this study were to explore and describe how HIV stigma and disclosure experiences impact the lives of PLWH and to explore whether there are differences between experiences in urban and rural settings. A qualitative approach was followed and participants were selected through purposive voluntary sampling. Data collection took place using in-depth interviews with 23 PLWH, 11 of whom resided in an urban setting in North-West, South Africa, and 12 resided in a rural setting in the same province. The data were manually analysed through open coding. The HIV stigma experiences expressed by PLWH depicted negative behavioural patterns and attitudes towards them, fear from the community of being infected by PLWH and lastly negative self-judgement by PLWH themselves. During disclosure, PLWH were unsure and they described it as a stressful event. They cautiously considered to whom to disclose their condition and what benefits disclosure will hold. They further had to handle forced disclosure due to being identifiable in health-care settings. HIV stigma and related disclosure practices remained a problem, which detrimentally affected treatment and support efforts. Recommendations focused on HIV stigma reduction in the community that needed to involve PLWH and PLC.

The effects of a mass media HIV-risk reduction strategy on HIV-related stigma and knowledge among African American adolescents

HIV-related stigma undermines HIV prevention, testing, and treatment. Multipronged risk-reduction strategies may reduce stigma among African American adolescents. To test the effectiveness of a risk-reduction strategy in addressing stigma, 1613 African American adolescents from four mid-sized cities participated in a randomized control trial. Participants received a sexual-risk reduction [Focus on Youth (FOY)] or general health curriculum [Promoting Health Among Teens (PHAT)]. Two cities received a culturally-tailored media intervention. Participants completed baseline, 3-, 6-, and 12-month surveys to measure HIV-related stigma and knowledge. Analysis of covariance tested for stigma and knowledge differences by media city status and curriculum/media city status (PHAT media vs. PHAT non-media, FOY media vs. FOY non-media; FOY media vs. PHAT media; FOY non-media vs. PHAT non-media) at each measurement. Hierarchical linear modeling (HLM) determined stigma and knowledge differences over time. Media participants demonstrated greater HIV-related knowledge (p<0.10) at 6 months and lower stigma at 3 months (p<0.10). FOY media participants had lower 3-month (p<0.05) and 12-month (p<0.10) stigma scores than non-media FOY participants. FOY media and non-media participants had greater knowledge than PHAT for all intervals after baseline. FOY media had lower stigma than PHAT media after baseline for all intervals after baseline. HLM indicated greater knowledge slopes for the media group (p<0.05). FOY media participants had greater knowledge slopes (p<0.05) relative to non-media FOY participants and media PHAT participants (p<0.01). A combination of a HIV risk-reduction curriculum and culturally-tailored media demonstrated some effectiveness in reducing stigma. Future use of media in HIV-prevention should include and evaluate effects on stigma.

HIV stigma experienced by young men who have sex with men (MSM) living with HIV infection

Stigma can compromise the health of persons living with HIV. Although HIV is increasingly affecting young men who have sex with men (MSM), little is known about their experiences with HIV stigma. We used narrative data to examine HIV stigma experienced by young MSM living with HIV. Data came from 28 qualitative interviews with young MSM. We used inductive content analysis to identify themes across these interviews. Participants commonly discussed negative perceptions and treatment of persons living with HIV. Stigma could result in nondisclosure of HIV status, internalized stigma, and avoidance of HIV-related things. Some men discussed strategies that might combat stigma. Findings suggest that HIV stigma might challenge young MSM's health by undermining health-conducive resources (e.g., social support) and contributing to HIV vulnerability. Interventions that counteract HIV stigma may help to create environments that promote well-being among young MSM living with HIV.

Loneliness, HIV-related stigma, and condom use among a predominantly rural sample of HIV-positive men who have sex with men (MSM)

Most previous studies of the sexual behaviors of men who have sex with men (MSM) living with HIV are based on samples recruited within relatively urban and suburban areas of the United States. Using an internet-based questionnaire, we assessed HIV-related stigma, loneliness, and event-level sexual behaviors in a sample of HIV positive MSM (n = 100) residing within a largely rural area in the Midwestern United States. HIV-related stigma was correlated with loneliness (r = 0.619, p < 0.01). Loneliness was negatively associated with condom usage with the most recent partner of unknown status (p < 0.05). Namely, a 1-unit increase in the UCLA loneliness score was met with a 10% decrease in odds of condom usage. Further studies are warranted that explore loneliness, within the context of HIV-related stigma, among HIV-positive MSM residing in rural areas. More refined data will inform clinical and social service practice, as they provide much-needed information on sexual health outcomes and experiences of an often underserved and under studied population.

Reflections on living with HIV over time: exploring the perspective of HIV-infected women over 50

OBJECTIVES

Approximately 32.7% of people living with HIV/AIDS (PLWHA) in the USA are now over the age of 50. Women comprise a significant percentage of the US HIV epidemic and the percentage of women diagnosed with HIV continues to grow; however, little is known about women's experiences living and coping with HIV over time. The goal of this study was to explore the experiences of US women over 50 living with HIV to better understand how they make sense of their diagnosis and cope with their illness over time and during the aging process.

METHOD

Nineteen women (mean age = 56.79, SD = 4.63) referred from Boston-area organizations and hospitals completed one-time, in-depth individual interviews, out of which 47% of the participants were identified as Black/African Americans, and 37% as White. The average time since diagnosis was 16.32 years (SD = 5.70). Inclusion criteria included: (1) female sex, (2) aged 50 or older, (3) HIV diagnosis, and (4) English speaking. Transcribed interviews were analyzed using a grounded theory approach and NVivo 9 software.

RESULTS

Findings are described across the following themes: (1) experiences at diagnosis, (2) uncertainty of disease course, (3) acceptance, and (4) living 'well' with HIV. Participants appeared to be well adjusted to their HIV diagnosis and described a progression to acceptance and survivorship; they identified strategies to 'live well' in the context of HIV. For some, health-related uncertainty about the future remained. These findings were organized into a model of coping with HIV.

CONCLUSION

Themes and issues identified by this study may help guide interventions across the lifespan for women with HIV.

Factors associated with risk of depression and relevant predictors of screening for depression in clinical practice: a cross-sectional study among HIV-infected individuals in Denmark

OBJECTIVES

Depression and psychiatric disorders are frequent among HIV-infected individuals. The aim of this study was to determine the prevalence of depression and describe the psychiatric history of HIV-infected individuals in an out-patient clinic in Denmark and to identify factors of clinical importance that may be used to identify patients at risk of depression.

METHODS

In 2013, 212 HIV-infected patients were included in a questionnaire study. We used the Beck Depression Inventory II (BDI-II) to assess the prevalence and severity of depressive symptoms. Patients with a BDI-II score ≥ 20 were offered a clinical evaluation by a consultant psychiatrist. Logistic regression was used to determine predictors associated with risk of depression.

RESULTS

Symptoms of depression (BDI-II score ≥ 14) were observed in 75 patients (35%), and symptoms of moderate to major depression (BDI-II score ≥ 20) in 55 patients (26%). There was also a high prevalence of co-occurring mental illness. In a multivariate model, self-reported stress, self-reported perception that HIV infection affects all aspects of life, self-reported poor health, not being satisfied with one's current life situation, previous alcohol abuse, nonadherence to antiretroviral therapy and previously having sought help because of psychological problems were independently associated with risk of depression.

CONCLUSIONS

Symptoms of depression and co-occurring mental illness are under-diagnosed and under-treated among HIV-infected individuals. We recommend that screening of depression should be conducted regularly to provide a full psychiatric profile to decrease the risk of depression and improve adherence and quality of life in this population.

Personal meaning, social support, and perceived stigma in individuals receiving HIV mental health services

Human immunodeficiency virus (HIV) stigma represents a significant source of stress among individuals living with HIV disease, prompting interest in research to identify factors that may help to ameliorate the stress burden associated with HIV stigma. Consistent with this research line, the current study was conducted as a cross-sectional investigation examining associations between positive global personal meaning, social support, and perceived HIV stigma. Global personal meaning refers to beliefs and aspirations through which one ascribes value and purpose in living. The study sample was comprised of individuals living with HIV disease who presented for an initial visit in a specialty HIV mental health services program. In bivariate analyses, social support was negatively correlated with multidimensional aspects of HIV stigma that included distancing, blaming, and discrimination stigma, whereas personal meaning was negatively associated only with blaming stigma. In further analyses using structural equation modeling, social support significantly mediated the association between personal meaning and both distancing and blaming stigma. Interactions between positive personal meaning and social support may be useful to consider in future research on psychological resource factors and HIV stigma. Understanding these interactions may also inform clinical efforts to address HIV stigma concerns.

HIV stigma and physical health symptoms: do social support, adaptive coping, and/or identity centrality act as resilience resources?

Despite efforts to eliminate it at the societal level, HIV stigma persists and continues to threaten the health of people living with HIV (PLWH). We tested whether social support, adaptive coping, and/or HIV identity centrality act as resilience resources by buffering people from the negative impact of enacted and/or anticipated stigma on stress and ultimately HIV symptoms. Ninety-three PLWH completed a survey, and data analyses tested for evidence of mediation and moderation. Results demonstrated that instrumental social support, perceived community support, and HIV identity centrality buffered participants from the association between anticipated stigma and HIV symptoms. That is, anticipated stigma was associated with HIV symptoms via stress only at low levels of these resources. No resources buffered participants from the impact of enacted stigma. Identifying and enhancing resilience resources among PLWH is critical for protecting PLWH from the harmful effects of stigma.

Psychometric evaluation of the HIV stigma scale in a Swedish context

Background

HIV-related stigma has negative consequences for infected people's lives and is a barrier to HIV prevention. Therefore valid and reliable instruments to measure stigma are needed to enable mapping of HIV stigma. This study aimed to evaluate the psychometric properties of the HIV stigma scale in a Swedish context with regard to construct validity, data quality, and reliability.

Methods

The HIV stigma scale, developed by Berger, Ferrans, and Lashley (2001), was distributed to a cross-sectional sample of people living with HIV in Sweden (n = 194). The psychometric evaluation included exploratory factor analysis together with an analysis of the distribution of scores, convergent validity by correlations between the HIV stigma scale and measures of emotional well-being, and an analysis of missing items and floor and ceiling effects. Reliability was assessed using Cronbach's α.

Results

The exploratory factor analysis suggested a four-factor solution, similar to the original scale, with the dimensions personalised stigma, disclosure concerns, negative self-image, and concerns with public attitudes. One item had unacceptably low loadings and was excluded. Correlations between stigma dimensions and emotional well-being were all in the expected direction and ranged between −0.494 and −0.210. The instrument generated data of acceptable quality except for participants who had not disclosed their HIV status to anybody. In line with the original scale, all subscales demonstrated acceptable internal consistency with Cronbach's α 0.87–0.96.

Conclusion

A 39-item version of the HIV stigma scale used in a Swedish context showed satisfactory construct validity and reliability. Response alternatives are suggested to be slightly revised for items assuming the disclosure of diagnosis to another person. We recommend that people that have not disclosed should skip all questions belonging to the dimension personalised stigma. Our analysis confirmed construct validity of the instrument even without this dimension.

Patient and provider perspectives on HIV and HIV-related stigma in Dutch health care settings

Ensuring that people living with HIV (PLWH) feel accepted in health care settings is imperative. This mixed methods study explored the perspectives of PLWH and health professionals on their interactions. A total of 262 predominantly gay men of Dutch origin participated in a survey study of possible negative interactions with health professionals, and semi-structured interviews were subsequently conducted with 22 PLWH and 14 health professionals. Again, most PLWH were gay men of Dutch origin. All health professionals were Dutch. PLWH reported negative experiences with health professionals including awkward interactions, irrelevant questions, rude treatment, blame, pity, excessive or differential precautions, care refusal, unnecessary referrals, delayed treatment, poor support, and confidentiality breaches. They also reported positive experiences including equal treatment, being valued as a partner in one's health, social support provision, and confidentiality assurances. Health professionals reported having little experience with PLWH and only basic knowledge of HIV. They contended that PLWH are treated equally and that HIV is no longer stigmatized, but also reported fear of occupational infection, resulting in differential precautions. Additionally, they conveyed labeling PLWH's files to warn others, and curiosity regarding how patients acquired HIV. The findings suggest that there is a gap in perception between PLWH and health professionals regarding the extent to which negative interactions occur, and that these interactions should be improved. Implications for stigma reduction and care optimization are discussed.

General and health-related Internet use among an urban, community-based sample of HIV-positive women: implications for intervention development

Internet-based HIV interventions are increasingly common, although little focus has been on HIV-positive women. To understand the feasibility of using the Internet to deliver behavioral interventions to HIV-positive women, we sought to describe patterns of Internet use for general and health-related purposes and to explore differences between Internet-using and non-using women. From February 2014 to April 2014, 103 women were recruited at six community-based organizations in the Bronx, NY that provide services to HIV-positive persons. Women completed a 30-minute interview and answered a brief survey of socio-demographic factors, risk behavior and clinical characteristics. We performed χ(2) and Kruskal-Wallis tests to compare Internet users and non-users. Sixty-one percent of participants were current Internet users, most of whom used a personal electronic device (e.g., cellphone/smartphone) to access the Internet. While higher proportions of Internet users were passively engaged (e.g., signed up to receive email updates [42.9%] or watched an online video [58.7%] for health-related purposes), smaller proportions (12.7-15.9%) were involved in more interactive activities such as posting comments, questions, or information about health-related issues in an online discussion or a blog. A majority of Internet non-users (60.0%) expressed interest in going online. Lack of computer or Internet access (37.5%) and Internet navigation skills (37.5%) were the primary reasons for non-use. Compared with non-users, Internet users were more likely to be younger, to have higher socioeconomic status, and to report low health-related social support. Despite having a lower proportion of Internet users in our study than the general population, Internet-using women in our study had relatively high levels of online engagement and went online for both general and health-related purposes. However, Internet-based interventions targeting HIV-positive women will likely need to include providing computer and/or Internet access as well as training participants in how to navigate the Internet.

The impact of HIV-related stigma on older and younger adults living with HIV disease: does age matter?

The purpose of this study was to examine the independent influence of age on levels of HIV-related stigma experienced by adults living with HIV/AIDS. To accomplish this, cross-sectional data from the Ontario HIV Treatment Network Cohort Study were used to determine whether older age is associated with overall stigma among HIV-positive adults living in Ontario, Canada (n = 960). The relationship was also tested for enacted, anticipated, and internalized stigma. Covariates included sociodemographic (e.g., gender, sexual orientation, race) and psychosocial variables (e.g., depression). Modifying effects of covariates were also investigated. Those 55 and older have significantly lower overall and internalized stigma than adults under age 40, even when accounting for gender, sexual orientation, income, time since diagnosis, depression, maladaptive coping, and social support. Age does not predict enacted or Anticipated Stigma when accounting for the demographic and psychosocial variables. A significant interaction between depression and age suggests that stigma declines with age among those who are depressed but increases to age 50 and then decreases in older age groups among those who are not depressed. Age matters when it comes to understanding stigma among adults living with HIV/AIDS; however, the relationship between age and stigma is complex, varying according to stigma type and depression level.

[Coping and perception of women with HIV infection]

OBJECTIVE

To analyze women’s perceptions and coping regarding the discovery of an HIV infection.

METHODS

A qualitative study in an HIV/AIDS Specialist Helpdesk in Recife, PE, Northeastern Brazil, from January to September 2010, involving eight women living with asymptomatic HIV aged between 27 and 37 years, without criteria for diagnosis of AIDS infected through intercourse and monitored by the service for at least one year. Forms were used to characterize the clinical situation and semi-structured interviews to understand perceptions and feelings related to personal trajectory after diagnosis and different ways of facing the diagnosis in family and social life. Content analysis was performed as suggested by Bardin.

RESULTS

The thematic category that emerged was stigma and discrimination. The women had life trajectories marked by stigma, which was perceived as discrimination after the diagnosis and in the experiences of everyday life. The revelation of the infection was perceived as limiting to a normal life, leading to the need to conceal the diagnosis. The discriminatory attitudes of some health care professionals, non-specialist in HIV/AIDS, had a negative impact on future experiences in other health services. Besides the effects of institutional stigma, the perception of women was that the service did not include dedicated space for the expression of other needs beyond the disease, which could help in fighting the infection.

CONCLUSIONS

Living with HIV was strongly linked to stigma. The results show the importance of strengthening educational approaches and emotional support at the time of diagnosis in order to facilitate coping with the condition of seropositivity.

Addressing Ebola-related stigma: lessons learned from HIV/AIDS

BACKGROUND

HIV/AIDS and Ebola Virus Disease (EVD) are contemporary epidemics associated with significant social stigma in which communities affected suffer from social rejection, violence, and diminished quality of life.

OBJECTIVE

To compare and contrast stigma related to HIV/AIDS and EVD, and strategically think how lessons learned from HIV stigma can be applied to the current EVD epidemic.

METHODS

To identify relevant articles about HIV/AIDS and EVD-related stigma, we conducted an extensive literature review using multiple search engines. PubMed was used to search for relevant peer-reviewed journal articles and Google for online sources. We also consulted the websites of the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and the National Institutes of Health to retrieve up-to-date information about EVD and HIV/AIDS.

RESULTS

Many stigmatizing attitudes and behaviors directed towards those with EVD are strikingly similar to those with HIV/AIDS but there are significant differences worthy of discussion. Both diseases are life-threatening and there is no medical cure. Additionally misinformation about affected groups and modes of transmission runs rampant. Unlike in persons with EVD, historically criminalized and marginalized populations carry a disproportionately higher risk for HIV infection. Moreover, mortality due to EVD occurs within a shorter time span as compared to HIV/AIDS.

CONCLUSIONS

Stigma disrupts quality of life, whether it is associated with HIV infection or EVD. When addressing EVD, we must think beyond the immediate clinical therapeutic response, to possible HIV implications of serum treatment. There are emerging social concerns of stigma associated with EVD infection and double stigma associated with EVD and HIV infection. Drawing upon lessons learned from HIV, we must work to empower and mobilize prominent members of the community, those who recovered from the disease, and organizations working at the grassroots level to disseminate clear and accurate information about EVD transmission and prevention while promoting stigma reduction in the process. In the long run, education, prevention, and a therapeutic vaccine will be the optimal solutions for reducing the stigma associated with both EVD and HIV.

"It is all about the fear of being discriminated [against]…the person suffering from HIV will not be accepted": a qualitative study exploring the reasons for loss to follow-up among HIV-positive youth in Kisumu, Kenya

BACKGROUND

Youth represent 40% of all new HIV infections in the world, 80% of which live in sub-Saharan Africa. Youth living with HIV (YLWH) are more likely to become lost to follow-up (LTFU) from care compared to all other age groups. This study explored the reasons for LTFU among YLWH in Kenya.

METHODS

Data was collected from: (1) Focus group Discussions (n = 18) with community health workers who work with LTFU youth. (2) Semi-structured interviews (n = 27) with HIV + youth (15-21 years old) that had not received HIV care for at least four months. (3) Semi-structured interviews (n = 10) with educators selected from schools attended by LTFU interview participants. Transcripts were coded and analyzed employing grounded theory.

RESULTS

HIV-related stigma was the overarching factor that led to LTFU among HIV + youth. Stigma operated on multiple levels to influence LTFU, including in the home/family, at school, and at the clinic. In all three settings, participants' fear of stigma due to disclosure of their HIV status contributed to LTFU. Likewise, in the three settings, the dependent relationships between youth and the key adult figures in their lives were also adversely impacted by stigma and resultant lack of disclosure. Thus, at all three settings stigma influenced fear of disclosure, which in turn impacted negatively on dependent relationships with adults on whom they rely (i.e. parents, teachers and clinicians) leading to LTFU.

CONCLUSIONS

Interventions focusing on reduction of stigma, increasing safe disclosure of HIV status, and improved dependent relationships may improve retention in care of YLWH.

Stigma, social support, and treatment adherence among HIV-positive patients in Chiang Mai, Thailand

Our study assessed the influence of HIV-related stigma on treatment adherence among people living with HIV in Chiang Mai, Thailand, and whether social support had a moderating effect on this relationship. We recruited 128 patients living with HIV from Sansai Hospital, a community hospital in Chiang Mai, Thailand, and collected data through structured interviews. All forms of HIV-related stigma considered in this study (personalized experience, disclosure, negative self-image, and public attitudes) were negatively correlated with adherence to anti-retroviral regimens. Multiple linear regression indicated that total HIV-related stigma was more predictive of treatment adherence than any individual stigma type, after adjusting for socio-demographic and health characteristics. Tests of interaction showed that social support did not appear to moderate the association between HIV stigma and treatment adherence. Our findings suggest that community and government efforts to improve public perceptions about people living with HIV might promote treatment adherence behaviors among HIV-positive patients.

The examination of emotion dysregulation as a moderator of depression and HIV-relevant outcome relations among an HIV+sample

The present study examined whether emotion dysregulation moderated the relations between depressive symptoms and HIV symptoms, HIV medication adherence due to medication side effects, avoidant coping, and distress tolerance among people living with HIV/AIDS (PLHA). Participants included 115 PLHA (16.8% female; Mage = 49.70, SD = 8.57). Results indicated that there was a significant interaction between depressive symptoms and emotion dysregulation in relation to HIV symptoms, HIV medication adherence due to medication side effects, avoidant coping, and distress tolerance. The form of the interaction indicated that PLHA experiencing higher depressive symptoms and higher levels of emotion dysregulation reported the highest levels of HIV symptoms and lowest levels of distress tolerance. Additionally, results indicated that at lower levels of depressive symptoms, very high levels of emotion dysregulation predicted higher rates of medication nonadherence, whereas at higher levels of depressive symptoms, very high levels of emotion dysregulation predicted the lowest rates of medication nonadherence. Moreover, those experiencing lower levels of depressive symptoms and higher levels of emotion dysregulation reported the greatest rates of avoidant coping. In total, the present results suggest a complex interplay between emotion dysregulation and depressive symptoms with regard to HIV symptoms, medication nonadherence, and self-regulatory processes (e.g., avoidant coping, distress tolerance) among PLHA.

Multi-level factors affecting entry into and engagement in the HIV continuum of care in Iringa, Tanzania

Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.

Risk and protective factors for retention in HIV care

Retention in care for HIV is essential for effective disease management; however, factors that may confer risk or protection for adherence to regular HIV care are less well understood. This study tested whether HIV-associated cognitive impairment (CI) and low health literacy reduced adherence to routine HIV medical and phlebotomy visits and if social support and patient-provider relationship conferred a protective effect. Participants were 210 HIV-infected patients enrolled in outpatient care and followed for 28-weeks. Results showed that those attending >75 % of phlebotomy visits were more likely to be virally suppressed. Health literacy was unassociated with adherence to medical or phlebotomy visits. CI was not directly related to medical or phlebotomy visit adherence; however those with CI and greater use of social support were less likely to miss medical visits. Utilizing social support may be an effective means of managing visit adherence, especially among patients with CI.

HIV stigma among substance abusing people living with HIV/AIDS: implications for HIV treatment

HIV-related stigma has a major impact on quality of life and health among people living with HIV and AIDS (PLWHA). This study examines demographic, mental health, behavioral, contextual, and HIV care-related correlates of HIV stigma among 503 substance abusing PLWHA. Stigma was measured with the HIV Internalized Stigma Measure which has four subscales: stereotypes about HIV, self-acceptance, disclosure concerns, and social relationships. Severe substance dependence (55.3%) and depression (54.7%) were associated with higher HIV stigma across all domains. 49.9% of the sample reported antiretroviral (ARV) medication diversion (the unlawful sale and trading of ARV medications); diverters endorsed significantly higher stigma related to disclosure. 54.1% of the sample reported ≥95% ARV adherence; these individuals reported significantly lower stigma for self-acceptance, disclosure, and social relationships. Multivariate linear regression showed that depression and social support demonstrated significant main effects across stigma domains. Findings suggest that interventions to decrease HIV related stigma may be an important component of initiatives to increase engagement in HIV care.

HIV stigma and unprotected sex among PLWH in KwaZulu-Natal, South Africa: a longitudinal exploration of mediating mechanisms

Social and structural factors including HIV stigma are theorized to drive global disparities in HIV prevalence. This study tests whether HIV self-stigma, or experiences of stigma at the individual level, is associated with engagement in unprotected sex among people living with HIV (PLWH) in KwaZulu-Natal, South Africa, where 37.4% of adults are living with HIV compared with 0.8% worldwide. It further explores whether depressive symptoms, HIV status disclosure to sex partners, and/or condom use attitudes mediate potential associations between HIV self-stigma and unprotected sex. Participants, including 924 PLWH, were recruited from primary care clinics and completed baseline, 6-, 12-, and 18-month survey assessments between 2008 and 2011. Hierarchical linear modeling analyses were used to examine longitudinal within-subjects associations between HIV self-stigma, mediators, and unprotected sex with both HIV-negative/unknown and HIV-positive partners. Results demonstrate that HIV self-stigma was prospectively associated with greater likelihood of unprotected sex with HIV-negative/unknown partners. None of the variables explored significantly mediated this association. HIV self-stigma was also prospectively associated with greater likelihood of unprotected sex with HIV-positive partners via the mediators of greater depressive symptoms and more negative condom use attitudes. The current study suggests that HIV self-stigma undermines HIV secondary prevention and care efforts among PLWH in KwaZulu-Natal. It is therefore critical to address HIV stigma at the social/structural level to reduce HIV self-stigma at the individual level and ultimately curb global disparities in HIV prevalence. In the absence of widespread social/structural change, interventions that treat depressive symptoms and encourage more positive condom use attitudes despite the existence of HIV stigma may buffer associations between HIV self-stigma and unprotected sex with HIV-positive partners among PLWH in KwaZulu-Natal.

Adjustment as process and outcome: Measuring adjustment to HIV in Uganda

'Adjustment' in health refers to both processes and outcomes. Its measurement and conceptualisation in African cultures is limited. In total, 263 people living with HIV and receiving anti-retroviral therapy in clinics in Uganda completed a translated Mental Adjustment to HIV Scale, depression items from the Hopkins checklist and demographic questions. Factor analysis revealed four Mental Adjustment to HIV factors of active coping, cognitive-social adjustment, hopelessness and denial/avoidance. Correlations with depression supported the Mental Adjustment to HIV's validity and the importance of active adjustment, while the role of cognitive adjustment was unclear. Factors were process or outcome focussed, suggesting a need for theory-based measures in general.

The Second Closet: A Qualitative Study of HIV Stigma Among Seropositive Gay Men in a Southern U.S. City

OBJECTIVES

Stigma connected with HIV/AIDS has decreased considerably since the early epidemic yet affects those living with HIV in many ways. Little research, particularly qualitative research, concerning HIV stigma from the perspective of gay men has emerged. The present qualitative study aimed to fill this evidence gap by examining how HIV stigma is perceived and experienced by gay men who have become HIV-infected and how they respond to this stigma.

METHODS

Thematic analysis of 19 gay men's narratives identified six main themes.

RESULTS

Encountering HIV stigmatization was common and was linked to the physical stigmata identifying respondents as HIV-positive. Overwhelmingly, they found stigmatization to be most intensely felt within gay communities. One profound theme was internalized HIV stigma, referring to respondents' internalized negative feelings about their HIV status. A related theme was the closeted nature of HIV. Lastly, regarding how the men dealt with the HIV diagnosis and experiences of HIV stigma, a theme of adaptation became clear.

CONCLUSIONS

Although exploratory, the results can serve as a beginning framework for understanding and assisting seropositive gay men who experience HIV stigma. The findings are important because it is realistic to expect that in a climate in which HIV has become increasingly invisible and closeted and in which infections are on the rise, gay and bisexual men will be increasingly affected and infected by HIV.

Association between efavirenz as initial therapy for HIV-1 infection and increased risk for suicidal ideation or attempted or completed suicide: an analysis of trial data

BACKGROUND

The relationship between efavirenz use and suicidality is not well-defined.

OBJECTIVE

To compare time to suicidality with efavirenz-containing versus efavirenz-free antiretroviral regimens for initial treatment of HIV.

DESIGN

Participant-level data were analyzed from 4 AIDS Clinical Trials Group, antiretroviral-naive studies conducted from 2001 to 2010. Within each study, participants were randomly assigned to an efavirenz-containing (n = 3241) or efavirenz-free (n = 2091) regimen. (ClinicalTrials.gov: NCT00013520 [A5095], NCT00050895 [A5142], NCT00084136 [A5175], and NCT00118898 [A5202]).

SETTING

AIDS Clinical Trials Group sites; 74% of participants enrolled in the United States.

PATIENTS

Antiretroviral-naive participants.

INTERVENTION

Efavirenz versus efavirenz-free regimens.

MEASUREMENTS

Suicidality was defined as suicidal ideation or attempted or completed suicide. Groups were compared with a hazard ratio and 95% CI estimated from a Cox model, stratified by study.

RESULTS

Seventy-three percent of participants were men, the median age was 37 years, and 32% had documented psychiatric history or received psychoactive medication within 30 days before entering the study. Median follow-up was 96 weeks. Suicidality incidence per 1000 person-years was 8.08 (47 events) in the efavirenz group and 3.66 (15 events) in the efavirenz-free group (hazard ratio, 2.28 [95% CI, 1.27 to 4.10]; P = 0.006). Incidence of attempted or completed suicide was 2.90 (17 events) and 1.22 (5 events) in the efavirenz and efavirenz-free groups, respectively (hazard ratio, 2.58 [CI, 0.94 to 7.06]; P = 0.065). Eight suicides in the efavirenz group and 1 in the efavirenz-free group were reported.

LIMITATION

There was not a standardized questionnaire about suicidal ideation or attempt. Efavirenz was open-label in 3 of 4 studies.

CONCLUSION

Initial treatment with an efavirenz-containing antiretroviral regimen was associated with a 2-fold increased hazard of suicidality compared with a regimen without efavirenz.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Evidence of impact: health, psychological and social effects of adult HIV on children

There is a growing evidence base on the immediate and short-term effects of adult HIV on children. We provide an overview of this literature, highlighting the multiple risks and resultant negative consequences stemming from adult HIV infection on the children they care for on an individual and family basis. We trace these consequences from their origin in the health and wellbeing of adults on whom children depend, through multiple pathways to negative impacts for children. As effective treatment reduces vertical transmission, the needs of affected children will predominate. Pathways include exposure to HIV in utero, poor caregiver mental or physical health, the impact of illness, stigma and increased poverty. We summarize the evidence of negative consequences, including those affecting health, cognitive development, education, child mental health, exposure to abuse and adolescent risk behaviour, including sexual risk behaviour, which has obvious implications for HIV-prevention efforts. We also highlight the evidence of positive outcomes, despite adversity, considering the importance of recognizing and supporting the development of resilience. This study is the first in a series of three commissioned by President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), the summary provided here was used to inform a second study which seeks to identify insights from the broader child development field which will help us predict what long-term negative consequences children affected by HIV and AIDS are likely to experience. The third study discusses the design of a model to estimate these consequences. Although comprehensive, the review is often hampered by poor-quality research, inadequate design, small sample sizes and single studies in some areas.

Effect of media use on HIV-related stigma in Sub-Saharan Africa: a cross-sectional study

It is known that HIV-related stigma hinders prevention efforts. Previous studies have documented that HIV-related stigma may be associated with socioeconomic and socioecological factors. Mass media use may moderate this association, but there is limited research addressing that possibility. In this study, based on cross-sectional data pooled from the 2006-2011 Demographic and Health Surveys of 11 sub-Saharan African countries (N = 204,343), we investigated the moderating effects of exposure to mass media on HIV-related stigma. Hierarchical regression analysis indicated that HIV-related stigma tends to be higher among rural residents and individuals with low levels of education and HIV knowledge, as well as those who do not know people living with HIV. Media use was generally associated with low levels of HIV-related stigma, and attenuated the gap between individuals with high and low educational levels. However, the effect of mass media was found to be stronger among urbanites rather than among rural residents, which could lead to a widening gap between the two groups in endorsement of HIV-related stigma. The implication of this study regarding the effect of media use on HIV-related stigma in sub-Saharan Africa is twofold: 1) mass media may have the potential to minimize the gap in HIV-related stigma between individuals with high and low educational levels, and hence future efforts of reducing HIV-related stigma in the region may benefit from utilizing media; 2) due perhaps to low media penetration to rural sub-Saharan Africa, mass media could have the unintended effect of widening the urban-rural gap further unless other more customized and rural-focused communication interventions are put in place.