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Weiser SD, Sheira LA, Weke E, Zakaras JM, Wekesa P, Frongillo EA, Burger RL, Mocello AR, Thirumurthy H, Dworkin SL, Tsai AC, Kahn JG, Butler LM, Bukusi EA, Cohen CR. An agricultural livelihood intervention is associated with reduced HIV stigma among people with HIV. AIDS 2024; 38:1553-1559. [PMID: 38752558 DOI: 10.1097/qad.0000000000003928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
OBJECTIVE HIV stigma undermines antiretroviral treatment (ART) adherence and viral suppression. Livelihood interventions may target drivers of negative attitudes towards people with HIV (PWH) by improving their health and strengthening their economic contributions. We examined the effects of a multisectoral agricultural livelihood intervention on HIV stigma among PWH in western Kenya. DESIGN Sixteen health facilities were randomly allocated (1 : 1) to intervention or control arms in Shamba Maisha , a cluster randomized controlled trial that aimed to improve HIV-related health through behavioral, mental health, and nutritional pathways. METHODS The intervention included a farming loan and agricultural and financial training. Participants had access to farmland and surface water and were at least 18 years old, on ART for more than 6 months, and moderately-to-severely food insecure. We measured internalized, anticipated, and enacted HIV stigma semiannually over 2 years using validated scales. In blinded intent-to-treat analyses, we compared changes in scores over 24 months by study arm, using longitudinal multilevel difference-in-differences linear regression models that accounted for clustering. RESULTS Of 720 enrolled participants (354 intervention), 55% were women, and the median age was 40 years [interquartile range 34-47 years]. Two-year retention was 94%. Compared with the control arm, the intervention resulted in significant decreases ( P < 0.001) of 0.42 points [95% confidence interval (CI) -0.52 to -0.31) in internalized stigma, 0.43 points (95% CI -0.51 to -0.34) in anticipated stigma, and 0.13 points (95% CI -0.16 to -0.09) in enacted stigma over 24 months. CONCLUSION The agricultural livelihood intervention reduced HIV stigma among PWH. Poverty-reduction approaches may be a novel strategy for reducing HIV stigma.
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Affiliation(s)
- Sheri D Weiser
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Lila A Sheira
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Elly Weke
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Jennifer M Zakaras
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Pauline Wekesa
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Edward A Frongillo
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, Discovery I, University of South Carolina, Columbia, SC
| | - Rachel L Burger
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Adrienne Rain Mocello
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Harsha Thirumurthy
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Blockley Hall, Philadelphia, PA
| | - Shari L Dworkin
- School of Nursing and Health Studies, University of Washington Bothell, Bothell, WA
| | - Alexander C Tsai
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA
| | - James G Kahn
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Lisa M Butler
- Institute for Collaboration on Health, Intervention, and Policy, University of Connecticut, Storrs, CT, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA
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Owuor PM, Miller JD, Kanugula SS, Yeam J, Collins S, Obure V, Arunga T, Otieno P, Olack B, Butler LM, Bukusi EA, Cohen CR, Weiser SD, Young SL. The influence of an agricultural intervention on social capital and water insecurity coping strategies: Qualitative evidence from female smallholder farmers living with HIV in western Kenya. Heliyon 2024; 10:e32058. [PMID: 38873679 PMCID: PMC11170164 DOI: 10.1016/j.heliyon.2024.e32058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 05/26/2024] [Accepted: 05/28/2024] [Indexed: 06/15/2024] Open
Abstract
Background Greater social capital is associated with positive health outcomes and better HIV management. The ways by which social capital may influence household water insecurity (HHWI), a critical determinant of health among persons living with HIV, remain underexplored. Further, despite the importance of reliable water access and use for health and agricultural productivity, few studies have described the strategies smallholder farmers living with HIV use to manage water insecurity. Objective We qualitatively explored how an agricultural intervention (provision of a treadle pump for irrigation) influenced HHWI coping strategies through its impacts on social capital among smallholder farmers living with HIV in western Kenya. Method In 2018, we purposively recruited participants from the Shamba Maisha study, a randomized agricultural intervention (NCT02815579) that provided irrigation pumps to improve treatment outcomes and food security among smallholder farmers living with HIV in western Kenya (n = 42). Participants shared their experiences with water insecurity through go-along and photo-elicitation interviews. Data were thematically analyzed using inductively developed codes. Results Participants described diverse strategies for coping with agricultural water insecurity. Dimensions of social capital such as feelings of belonging, connectedness, and trust influenced the use of the treadle water pump and other water access behaviors. For instance, participants reported borrowing or sharing water pumps with friends and neighbors if they felt they had a good rapport. In addition, participants indicated a willingness to engage in collective activities, such as supporting the operation of the irrigation pump during planting, when they felt sufficiently connected to a larger group. Overall, individuals in the intervention arm described greater social cohesion, reciprocity, and community connectedness than those in the control arm. Conclusion The impact of an agricultural intervention on water access and use was described as being modified by social capital among female smallholder farmers living with HIV. Findings suggest that social capital may create an enabling environment for implementing strategies that improve the management and reduce the burden of HIV. Measuring these strategies and their associations with HIV outcomes may strengthen our understanding of resilience among female smallholder farmers living with HIV. The development of a coping strategies index and its use in a longitudinal study could help to identify pathways through which social capital influences health and the effectiveness of livelihood interventions.
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Affiliation(s)
- Patrick M. Owuor
- Department of Anthropology, Northwestern University, Evanston, IL, 60208, USA
- Department of Anthropology, Wayne State University, Detroit, MI, 48201, USA
| | - Joshua D. Miller
- Department of Anthropology, Northwestern University, Evanston, IL, 60208, USA
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Samanvi S. Kanugula
- Department of Anthropology, Northwestern University, Evanston, IL, 60208, USA
| | - Joohee Yeam
- Department of Anthropology, Northwestern University, Evanston, IL, 60208, USA
| | - Shalean Collins
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, 70112, USA
| | - Valeria Obure
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Titus Arunga
- Institute for Policy Research, Northwestern University, Illinois, 60208, USA
| | | | - Beatrice Olack
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Lisa M. Butler
- Department of Public Health Services, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | | | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Sheri D. Weiser
- Department of Medicine, University of California San Francisco, San Francisco, CA, 94115, USA
| | - Sera L. Young
- Department of Anthropology, Northwestern University, Evanston, IL, 60208, USA
- Institute for Policy Research, Northwestern University, Illinois, 60208, USA
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Ferguson L, Gruskin S, Bolshakova M, Rozelle M, Yagyu S, Kasoka K, Oraro-Lawrence T, Motala A, Stackpool-Moore L, Hempel S. Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination. AIDS 2023; 37:1919-1939. [PMID: 37352492 PMCID: PMC10552822 DOI: 10.1097/qad.0000000000003628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023]
Abstract
A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.
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Affiliation(s)
- Laura Ferguson
- Institute on Inequalities in Global Health, University of Southern California
| | - Sofia Gruskin
- Institute on Inequalities in Global Health, University of Southern California
| | - Maria Bolshakova
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Mary Rozelle
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Sachi Yagyu
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | | | | | - Aneesa Motala
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | | | - Susanne Hempel
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
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4
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Wanjala SW, Nyongesa MK, Mapenzi R, Luchters S, Abubakar A. A qualitative inquiry of experiences of HIV-related stigma and its effects among people living with HIV on treatment in rural Kilifi, Kenya. Front Public Health 2023; 11:1188446. [PMID: 37427260 PMCID: PMC10324964 DOI: 10.3389/fpubh.2023.1188446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/25/2023] [Indexed: 07/11/2023] Open
Abstract
Background The pervasiveness of HIV-related stigma and discrimination, and its consequences on HIV prevention and treatment, have been well documented. However, little is known about the lived experiences of HIV-related stigma and its effects among the general adult population living with HIV in rural African settings. This study set out to explore this knowledge gap. Methods From April to June 2018, we conducted in-depth interviews with a convenience sample of 40 adults living with HIV aged 18-58 years in Kilifi, Kenya. A semi-structured interview guide was used to explore experiences of HIV-related stigma and its impact on these adults. A framework approach was used to analyze the data using NVIVO 11 software. Results Participants reported experiences of HIV-related stigma in its various forms (anticipated, perceived, internalised, and enacted), as well as its effects on HIV treatment and social and personal spheres. The internalisation of stigma caused by enacted stigma impacted care-seeking behavior resulting in worse overall health. Anxiety and depression characterized by suicidal ideation were the results of internalised stigma. Anticipated stigma prompted HIV medication concealment, care-seeking in remote healthcare facilities, and care avoidance. Fewer social interactions and marital conflicts resulted from perceived stigma. Overall, HIV-related stigma resulted in partial and non-disclosure of HIV seropositivity and medication non-adherence. At a personal level, mental health issues and diminished sexual or marital prospects (for the unmarried) were reported. Conclusion Despite high awareness of HIV and AIDS among the general population in Kenya, adults living with HIV in rural Kilifi still experience different forms of HIV-related stigma (including self-stigma) that result in a raft of social, personal, and HIV-treatment-related consequences. Our findings underscore the urgent need to reevaluate and adopt more effective strategies for implementing HIV-related anti-stigma programs at the community level. Addressing individual-level stigma will require the design of targeted interventions. To improve the lives of adults living with HIV in Kilifi, the effects of HIV-related stigma, particularly on HIV treatment, must be addressed.
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Affiliation(s)
- Stanley W. Wanjala
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Social Sciences, School of Humanities and Social Sciences, Pwani University, Kilifi, Kenya
| | - Moses K. Nyongesa
- Neuroassessment Group, KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Rachael Mapenzi
- Neuroassessment Group, KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
| | - Stanley Luchters
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Amina Abubakar
- Neuroassessment Group, KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
- Department of Public Health, School of Human and Health Sciences, Pwani University, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Kafu C, Wachira J, Omodi V, Said J, Pastakia SD, Tran DN, Onyango JA, Aburi D, Wilson-Barthes M, Galárraga O, Genberg BL. Integrating community-based HIV and non-communicable disease care with microfinance groups: a feasibility study in Western Kenya. Pilot Feasibility Stud 2022; 8:266. [PMID: 36578093 PMCID: PMC9795156 DOI: 10.1186/s40814-022-01218-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 11/29/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The Harambee study is a cluster randomized trial in Western Kenya that tests the effect, mechanisms, and cost-effectiveness of integrating community-based HIV and non-communicable disease care within microfinance groups on chronic disease treatment outcomes. This paper documents the stages of our feasibility study conducted in preparation for the Harambee trial, which include (1) characterizing the target population and gauging recruitment capacity, (2) determining community acceptability of the integrated intervention and study procedures, and (3) identifying key implementation considerations prior to study start. METHODS Feasibility research took place between November 2019 and February 2020 in Western Kenya. Mixed methods data collection included surveys administered to 115 leaders of 105 community-based microfinance groups, 7 in-person meetings and two workshops with stakeholders from multiple sectors of the health system, and ascertainment of field notes and geographic coordinates for group meeting locations and HIV healthcare facilities. Quantitative survey data were analyzed using STATA IC/13. Longitude and latitude coordinates were mapped to county boundaries using Esri ArcMap. Qualitative data obtained from stakeholder meetings and field notes were analyzed thematically. RESULTS Of the 105 surveyed microfinance groups, 77 met eligibility criteria. Eligible groups had been in existence from 6 months to 18 years and had an average of 22 members. The majority (64%) of groups had at least one member who owned a smartphone. The definition of "active" membership and model of saving and lending differed across groups. Stakeholders perceived the community-based intervention and trial procedures to be acceptable given the minimal risks to participants and the potential to improve HIV treatment outcomes while facilitating care integration. Potential challenges identified by stakeholders included possible conflicts between the trial and existing community-based interventions, fear of group disintegration prior to trial end, clinicians' inability to draw blood for viral load testing in the community, and deviations from standard care protocols. CONCLUSIONS This study revealed that it was feasible to recruit the number of microfinance groups necessary to ensure that our clinical trial was sufficient powered. Elicitation of stakeholder feedback confirmed that the planned intervention was largely acceptable and was critical to identifying challenges prior to implementation. TRIAL REGISTRATION The original trial was prospectively registered with ClinicalTrials.gov (NCT04417127) on 4 June 2020.
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Affiliation(s)
- Catherine Kafu
- Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya. .,School of Literature, Language and Media, Department of Media Studies, University of Witwatersrand, 1 Jan Smuts Avenue, Braamfontein, Johannesburg, 2000, South Africa.
| | - Juddy Wachira
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Behavioral Science, Moi University College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Victor Omodi
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Jamil Said
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.79730.3a0000 0001 0495 4256School of Medicine, Department of Human Anatomy, Moi University College of Health Sciences, P.O. Box 4606-30100, Eldoret, Kenya
| | - Sonak D. Pastakia
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.169077.e0000 0004 1937 2197Center for Health Equity and Innovation, Purdue University College of Pharmacy, 640 Eskenazi Ave, Indianapolis, IN 46202 USA
| | - Dan N. Tran
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya ,grid.264727.20000 0001 2248 3398Department of Pharmacy Practice, Temple University School of Pharmacy, 3307 N Broad St, Philadelphia, PA 19140 USA
| | - Jael Adongo Onyango
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Dan Aburi
- grid.512535.50000 0004 4687 6948Academic Model Providing Access to Healthcare, P.O. Box 4606-30100, Eldoret, Kenya
| | - Marta Wilson-Barthes
- grid.40263.330000 0004 1936 9094Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912 USA
| | - Omar Galárraga
- grid.40263.330000 0004 1936 9094Department of Health Services, Policy and Practice, Brown University School of Public Health, 121 South Main Street, Providence, RI 02912 USA
| | - Becky Lynn Genberg
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205 USA
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Ndlazi GJ, Hanley S, Maddocks ST, Chetty V. Perceptions of women enrolled in a cardiovascular disease screening and prevention in HIV study. S Afr Fam Pract (2004) 2022. [DOI: 10.4102/safp.v64i1.5554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Joseph NK, Macharia PM, Okiro EA. Progress towards achieving child survival goals in Kenya after devolution: Geospatial analysis with scenario-based projections, 2015-2025. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000686. [PMID: 36962627 PMCID: PMC10021401 DOI: 10.1371/journal.pgph.0000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/07/2022] [Indexed: 06/18/2023]
Abstract
Subnational projections of under-5 mortality (U5M) have increasingly become an essential planning tool to support Sustainable Development Goals (SDGs) agenda and strategies for improving child survival. To support child health policy, planning, and tracking child development goals in Kenya, we projected U5M at units of health decision making. County-specific annual U5M were estimated using a multivariable Bayesian space-time hierarchical model based on intervention coverage from four alternate intervention scale-up scenarios assuming 1) the highest subnational intervention coverage in 2014, 2) projected coverage based on the fastest county-specific rate of change observed in the period between 2003-2014 for each intervention, 3) the projected national coverage based on 2003-2014 trends and 4) the country-specific targets of intervention coverage relative to business as usual (BAU) scenario. We compared the percentage change in U5M based on the four scale-up scenarios relative to BAU and examined the likelihood of reaching SDG 3.2 target of at least 25 deaths/1,000 livebirths by 2022 and 2025. Projections based on 10 factors assuming BAU, showed marginal reductions in U5M across counties with all the counties except Mandera county not achieving the SDG 3.2 target by 2025. Further, substantial reductions in U5M would be achieved based on the various intervention scale-up scenarios, with 63.8% (30), 74.5% (35), 46.8% (22) and 61.7% (29) counties achieving SDG target for scenarios 1,2,3 and 4 respectively by 2025. Scenario 2 yielded the highest reductions of U5M with individual scale-up of access to improved water, recommended treatment of fever and accelerated HIV prevalence reduction showing considerable impact on U5M reduction (≥ 20%) relative to BAU. Our results indicate that sustaining an ambitious intervention scale-up strategy matching the fastest rate observed between 2003-2014 would substantially reduce U5M in Kenya. However, despite this ambitious scale-up scenario, 25% (12 of 47) of the Kenya's counties would still not achieve SDG 3.2 target by 2025.
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Affiliation(s)
- Noel K. Joseph
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peter M. Macharia
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, United Kingdom
| | - Emelda A. Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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8
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Nardell MF, Adeoti O, Peters C, Kakuhikire B, Govathson-Mandimika C, Long L, Pascoe S, Tsai AC, Katz IT. Men missing from the HIV care continuum in sub-Saharan Africa: a meta-analysis and meta-synthesis. J Int AIDS Soc 2022; 25:e25889. [PMID: 35324089 PMCID: PMC8944222 DOI: 10.1002/jia2.25889] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 02/01/2022] [Indexed: 02/03/2023] Open
Abstract
Introduction Men are missing along the HIV care continuum. However, the estimated proportions of men in sub‐Saharan Africa meeting the UNAIDS 95‐95‐95 goals vary substantially between studies. We sought to estimate proportions of men meeting each of the 95‐95‐95 goals across studies in sub‐Saharan Africa, describe heterogeneity, and summarize qualitative evidence on factors influencing care engagement. Methods We systematically searched PubMed and Embase for peer‐reviewed articles published between 1 January 2014 and 16 October 2020. We included studies involving men ≥15 years old, with data from 2009 onward, reporting on at least one 95‐95‐95 goal in sub‐Saharan Africa. We estimated pooled proportions of men meeting these goals using DerSimonion‐Laird random effects models, stratifying by study population (e.g. studies focusing exclusively on men who have sex with men vs. studies that did not), facility setting (healthcare vs. community site), region (eastern/southern Africa vs. western/central Africa), outcome measurement (e.g. threshold for viral load suppression), median year of data collection (before vs. during or after 2017) and quality criteria. Data from qualitative studies exploring barriers to men's HIV care engagement were summarized using meta‐synthesis. Results and discussion We screened 14,896 studies and included 129 studies in the meta‐analysis, compiling data over the data collection period. Forty‐seven studies reported data on knowledge of serostatus, 43 studies reported on antiretroviral therapy use and 74 studies reported on viral suppression. Approximately half of men with HIV reported not knowing their status (0.49 [95% CI, 0.41–0.58; range, 0.09–0.97]) or not being on treatment (0.58 [95% CI, 0.51–0.65; range, 0.07–0.97]), while over three‐quarters of men achieved viral suppression on treatment (0.79 [95% CI, 0.77–0.81; range, 0.39–0.97]. Heterogeneity was high, with variation in estimates across study populations, settings and outcomes. The meta‐synthesis of 40 studies identified three primary domains in which men described risks associated with engagement in HIV care: perceived social norms, health system challenges and poverty. Conclusions Psychosocial and systems‐level interventions that change men's perceptions of social norms, improve trust in and accessibility of the health system, and address costs of accessing care are needed to better engage men, especially in HIV testing and treatment.
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Affiliation(s)
- Maria F Nardell
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Oluwatomi Adeoti
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Carson Peters
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Bernard Kakuhikire
- Faculty of Business and Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Caroline Govathson-Mandimika
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sophie Pascoe
- Health Economics and Epidemiology Research Office, University of the Witwatersrand, Johannesburg, South Africa.,Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ingrid T Katz
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Global Health Institute, Cambridge, Massachusetts, USA
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9
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Hosaka KRJ, Mmbaga BT, Gallis JA, Dow DE. Feasibility and acceptability of a peer youth led curriculum to improve HIV knowledge in Northern Tanzania: resilience and intervention experience from the perspective of peer leaders. BMC Public Health 2021; 21:1925. [PMID: 34688254 PMCID: PMC8542314 DOI: 10.1186/s12889-021-11876-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Youth Living with HIV (YLWH) have reduced adherence to antiretroviral therapy (ART) and worse virologic outcomes compared to children and adults. HIV peer youth led (PYL) interventions contribute to improved retention in care and psychosocial wellbeing. The study objective was to assess the feasibility and acceptability of a PYL HIV curriculum and describe change in participants' knowledge and impact of leadership on peer leaders' lives. METHODS An HIV curriculum was taught during monthly Saturday adolescent HIV clinics at two clinical sites in Moshi, Tanzania (2018-2019). Youth attending clinics were ages 12 to 24 years and received the HIV curriculum during routine clinical care. Peer leaders previously participated in a mental health and life skills intervention called Sauti ya Vijana (The Voice of Youth; SYV) and were recommended for leadership by SYV facilitators and clinic staff. Peer leaders were trained and supervised weekly in curriculum delivery using a "train the trainer" model. Data were collected and analyzed using mixed methods. Fidelity checklists were used to measure adherence to the curriculum. Youth participants answered written pre- and post-knowledge questions and evaluated PYL teaching. Semi-structured interviews and the Connor Davidson Resilience scale were conducted with peer leaders before and after assuming the leadership role. RESULTS Peer leaders (N = 4 male; 3 female) demonstrated high fidelity (96%) to activities in each lesson and participant feedback was positive for curriculum delivery. Participants' knowledge improved in nine of ten sessions. All but one leader-who moved away before the study ended-demonstrated stable or improved resilience with a mean difference of 3.8 (SD = 7.0) from before the intervention to after assuming the leadership role. Peer leaders reported improved leadership confidence and resilience, and their perception was that the curriculum helped normalize the HIV experience for YLWH attending clinic. Nevertheless, anticipated stigma, difficulty disclosing HIV status, and teaching ability remained barriers. CONCLUSIONS This study demonstrated that a PYL curriculum to improve HIV knowledge integrated into routine adolescent HIV clinic in Tanzania was feasible, acceptable, and improved knowledge while also benefiting peer leaders, thus providing evidence to continue to support efforts to scale and sustain PYL interventions for YLWH.
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Affiliation(s)
- Kalei R J Hosaka
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA.
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Research Institute, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
| | - John A Gallis
- Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | - Dorothy E Dow
- Duke Global Health Institute, Duke University Medical Center, Durham, NC, USA
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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Genberg BL, Wilson-Barthes MG, Omodi V, Hogan JW, Steingrimsson J, Wachira J, Pastakia S, Tran DN, Kiragu ZW, Ruhl LJ, Rosenberg M, Kimaiyo S, Galárraga O. Microfinance, retention in care, and mortality among patients enrolled in HIV care in East Africa. AIDS 2021; 35:1997-2005. [PMID: 34115646 PMCID: PMC8963387 DOI: 10.1097/qad.0000000000002987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To measure associations between participation in community-based microfinance groups, retention in HIV care, and death among people with HIV (PWH) in low-resource settings. DESIGN AND METHODS We prospectively analyzed data from 3609 patients enrolled in an HIV care program in western Kenya. HIV patients who were eligible and chose to participate in a Group Integrated Savings for Health Empowerment (GISHE) microfinance group were matched 1 : 2 on age, sex, year of enrollment in HIV care, and location of initial HIV clinic visit to patients not participating in GISHE. Follow-up data were abstracted from medical records from January 2018 through February 2020. Logistic regression analysis examined associations between GISHE participation and two outcomes: retention in HIV care (i.e. >1 HIV care visit attended within 6 months prior to the end of follow-up) and death. Socioeconomic factors associated with HIV outcomes were included in adjusted models. RESULTS The study population was majority women (78.3%) with a median age of 37.4 years. Microfinance group participants were more likely to be retained in care relative to HIV patients not participating in a microfinance group [adjusted odds ratio (aOR) = 1.31, 95% confidence interval (CI) 1.01-1.71; P = 0.046]. Participation in group microfinance was associated with a reduced odds of death during the follow-up period (aOR = 0.57, 95% CI 0.28-1.09; P = 0.105). CONCLUSION Participation in group-based microfinance appears to be associated with better HIV treatment outcomes. A randomized trial is needed to assess whether microfinance groups can improve clinical and socioeconomic outcomes among PWH in similar settings.
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Affiliation(s)
- Becky L. Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Marta G. Wilson-Barthes
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Victor Omodi
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Joseph W. Hogan
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Jon Steingrimsson
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Juddy Wachira
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Behavioral Science, Moi University College of Health Sciences, School of Medicine, Eldoret, Kenya
| | - Sonak Pastakia
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Purdue University College of Pharmacy, Center for Health Equity and Innovation, Indianapolis, Indiana
| | - Dan N. Tran
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, Pennsylvania
| | - Zana W. Kiragu
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts
| | - Laura J. Ruhl
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
- Department of Medicine, Indiana University School of Medicine, Indianapolis
| | - Molly Rosenberg
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana
| | | | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
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11
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Tsai AC, Kakuhikire B, Perkins JM, Downey JM, Baguma C, Satinsky EN, Gumisiriza P, Kananura J, Bangsberg DR. Normative vs personal attitudes toward persons with HIV, and the mediating role of perceived HIV stigma in rural Uganda. J Glob Health 2021; 11:04956. [PMID: 34552725 PMCID: PMC8442577 DOI: 10.7189/jogh.11.04056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background HIV stigma has well-documented negative impacts on HIV testing, transmission risk behavior, initiation of and adherence to antiretroviral therapy, and retention in care. We sought to assess the extent to which anticipated HIV stigma is based on misperceptions of normative attitudes toward persons with HIV, and to determine whether persons with HIV have stronger misperceptions compared with HIV-negative persons or persons of unknown serostatus. We also sought to estimate the association between normative attitudes about persons with HIV and personal attitudes about persons with HIV, and to determine the extent to which anticipated stigma mediates this association. Methods We conducted a whole-population survey of 1776 persons living in 8 rural villages in southwestern Uganda. Negative attitudes toward persons with HIV, and anticipated stigma, were measured using a newly validated 15-item scale measuring multiple dimensions of HIV stigma, including social distance, blaming attitudes, and concerns about reciprocity. We used multivariable regression to estimate the association between normative attitudes about persons with HIV and personal attitudes toward persons with HIV, and to determine the extent to which perceptions of normative attitudes (anticipated stigma) mediated this association. Results Study participants believed that negative attitudes toward persons with HIV were more pervasive than they actually are. Perceptions of the extent to which these negative attitudes are normative mediated more than one-third of the association between normative attitudes and their personal attitudes. In contrast to what we originally hypothesized, persons with HIV were less likely to misperceive these norms and perceived normative attitudes to be less stigmatizing than did others in the general population. Conclusions Interventions designed to accurately describe normative attitudes toward persons with HIV may reduce HIV stigma without directly focusing on the educational components that are typically embedded in anti-stigma interventions.
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Affiliation(s)
- Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emily N Satinsky
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Justus Kananura
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David R Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda.,Oregon Health Sciences University-Portland State University School of Public Health, Portland, Oregon, USA
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12
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Njejimana N, Gómez-Tatay L, Hernández-Andreu JM. HIV-AIDS Stigma in Burundi: A Qualitative Descriptive Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179300. [PMID: 34501890 PMCID: PMC8431207 DOI: 10.3390/ijerph18179300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/27/2021] [Accepted: 08/29/2021] [Indexed: 11/30/2022]
Abstract
HIV/AIDS stigma is a global issue and a serious problem in African countries. Although prevalence remains high in this region, no detailed study has yet been carried out to determine and characterize this problem in Burundi. Using a qualitative analysis based on an extensive series of 114 interviews, we describe the main characteristics of HIV stigma in the country. The results of our study indicate that the problem of HIV/AIDS stigma is widespread in Burundian society, as all participants in the research reported having experienced some kind of HIV stigma. The seven dimensions of stigma identified in people living with HIV/AIDS (PLWHA) in Burundi are physical violence, verbal violence, marginalization, discrimination, self-stigma, fear and insecurity, and healthcare provider stigma. These dimensions of stigma can be experienced through different manifestations, which have been characterized in this study, revealing that the problem of stigma in PLWHA is still an important issue in Burundi.
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Affiliation(s)
- Néstor Njejimana
- Escuela de Doctorado, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain;
| | - Lucía Gómez-Tatay
- Institute of Life Sciences, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain;
- Grupo de Medicina Molecular y Mitocondrial, Facultad de Ciencias de la Salud, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain
- Correspondence:
| | - José Miguel Hernández-Andreu
- Institute of Life Sciences, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain;
- Grupo de Medicina Molecular y Mitocondrial, Facultad de Ciencias de la Salud, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain
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13
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Sileo KM, Wanyenze RK, Mukasa B, Musoke W, Kiene SM. The Intersection of Inequitable Gender Norm Endorsement and HIV Stigma: Implications for HIV Care Engagement for Men in Ugandan Fishing Communities. AIDS Behav 2021; 25:2863-2874. [PMID: 33566214 DOI: 10.1007/s10461-021-03176-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2021] [Indexed: 11/24/2022]
Abstract
Men's engagement in the HIV care continuum may be negatively affected by adherence to inequitable gender norms, which may be exacerbated by HIV stigma. This cross-sectional study with 300 male fisherfolk in Uganda examined the independent and interacting effects of inequitable gender norm endorsement and HIV stigma on men's missed HIV care appointments and missed antiretroviral (ARV) doses. Greater gender inequitable norm endorsement was associated with increased odds of missed HIV clinic visits (adjusted odds ratio [AOR)] 1.44, 95% CI 1.16-1.78) and a statistically significant interaction between internalized HIV stigma and inequitable gender norms on missed ARV doses was identified (AOR 5.32, 95% CI 2.60-10.86). Adherence to traditional gender norms reduces men's HIV appointment attendance, and among men with high internalized stigma, increases the likelihood of poor treatment adherence. These findings point to the need for HIV interventions that reconfigure harmful gender norms with a focus on stigma reduction.
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Affiliation(s)
- K M Sileo
- Department of Public Health, University of Texas At San Antonio, One UTSA Circle, MB 3.472, San Antonio, TX, 78249, USA.
- SDSU School of Public Health, San Diego State University, San Diego, CA, USA.
| | - R K Wanyenze
- Makerere School of Public Health, Makerere University, Kampala, Uganda
| | | | | | - S M Kiene
- SDSU School of Public Health, San Diego State University, San Diego, CA, USA
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Shamsaei F, Tahour N, Sadeghian E. Effect of Stress Management Training on Stigma and Social Phobia in HIV-Positive Women. J Int Assoc Provid AIDS Care 2021; 19:2325958220918953. [PMID: 32274969 PMCID: PMC7153174 DOI: 10.1177/2325958220918953] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The purpose of this study was to investigate the effect of stress management training on stigma and social phobia among HIV-positive women. This quasi-experimental pre- and posttest study was performed on a single group of 55 HIV-positive females Hamadan city, Iran, in 2018. The samples were taken through a convenience sampling method and the data collection tool were Berger HIV Stigma and Connor Social Phobia Scale. The mean scores of the stigma were 119.98 ± 21.15 and 94.78 ± 16.34 and social phobia were 24 ± 17.4 and 11.2 ± 9.68 before and after the intervention, respectively. The results of the paired sample t test indicated a significant difference in the stigma and social phobia mean scores before and after the intervention in HIV-positive women (P < .05). The results of the study revealed that stigma and social phobia are big challenges for HIV-positive women since these people are always judged by others and are subjected to labeling and rejection.
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Affiliation(s)
- Farshid Shamsaei
- Behavioral Disorders and Substance Abuse Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Neda Tahour
- Department of Nursing, School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Efat Sadeghian
- Chronic Diseases (Home Care) Research Centre, Hamadan University of Medical Sciences, Hamadan, Iran
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15
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Integrated psychosocial, economic strengthening, and clinical service-delivery to improve health and resilience of adolescents living with HIV and their caregivers: Findings from a prospective cohort study in Zambia. PLoS One 2021; 16:e0243822. [PMID: 33481776 PMCID: PMC7822390 DOI: 10.1371/journal.pone.0243822] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 11/27/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Children and youth are profoundly impacted groups in Zambia's HIV epidemic. To evaluate delivery of integrated psychosocial, economic strengthening, and clinical services to HIV-affected households through the Zambia Family (ZAMFAM) Project, a prospective cohort study compared socio-economic, psychosocial, and health outcomes among ZAMFAM beneficiaries to non-beneficiaries. METHODS In July-October 2017, 544 adolescents living with HIV (ALHIV) aged 5-17 years and their adult caregivers were recruited from Central (ZAMFAM implementation sites) and Eastern (non-intervention sites) Provinces. Structured interviews at baseline and one-year follow-up assessed household characteristics, socio-economic wellbeing, and health service utilization. Poisson regression with generalized estimating equations measured one-year changes in key health and socio-economic indicators, comparing ZAMFAM beneficiaries to non-beneficiaries. RESULTS Overall, 494 households completed two rounds of assessment (retention rate: 91%) Among ALHIV, improvements in current antiretroviral therapy use over time (Adjusted Prevalence Rate Ratio [aPRR] = 1.06, 95% Confidence Interval [95% CI]: 1.01-1.11) and reductions in non-household labor (aPRR = 0.44, 95% CI: 0.20-0.99) were significantly larger among ZAMFAM beneficiaries than non-beneficiaries. For caregivers, receiving ZAMFAM services was associated with significant reductions in HIV-related stigma (aPRR = 0.49, 95% CI: 0.28-0.88) and perceived negative community attitudes towards HIV (aPRR = 0.77, 95% CI: 0.62-0.96). Improvements in caregiver capacity to pay for unexpected (aPRR = 1.54, 95% CI: 1.17-2.04) and food-related expenses (aPRR = 1.48, 95% CI: 1.16-1.90), as well as shared decision-making authority in household spending (aPRR = 1.41, 95% CI: 1.04-1.93) and self-reported good or very good health status (aPRR = 1.46, 95% CI: 1.14-1.87), were also significantly larger among ZAMFAM beneficiaries. CONCLUSIONS Significant improvements in caregivers' financial capacity were observed among households receiving ZAMFAM services, with few changes in health or wellbeing among ALHIV. Integrated service-delivery approaches like ZAMFAM may yield observable socio-economic improvements in the short-term. Strengthening community-based delivery of psychosocial and health support to ALHIV is encouraged.
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Chan BT, Chakrapani V, Tsai AC. HIV-related stigma trends in the general population of India during an era of antiretroviral treatment expansion, 2005-16. J Glob Health 2020; 10:020420. [PMID: 33274063 PMCID: PMC7698569 DOI: 10.7189/jogh.10.020420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In India, which has the world's third-largest HIV epidemic, the extent to which levels of HIV-related stigma have changed during an era of ART scale-up is unknown. METHODS We analyzed data from the 2005-06 and 2015-16 National Family Health Surveys (NFHS) to estimate trends in two stigma domains among people in the general population: desires for social distance from people living with HIV (ie, unwillingness to interact) and fear of serostatus disclosure in the case of a hypothetical HIV infection. We fitted multivariable linear probability models to the data with year of NFHS as the explanatory variable and alternately specifying fear of disclosure or desires for social distance as the dependent variable. Analyses were stratified by sex, state, and high vs low HIV prevalence states. RESULTS We included data on 172 795 women and 159 194 men. Desires for social distance declined in 2015-16 compared with 2005-06 (38% in 2015-16 vs 43% in 2005-06; adjusted b = -0.046; 95% confidence interval (CI = -0.049 to -0.043; P < 0.001) but fear of serostatus disclosure increased (31% in 2005-06 vs 37% in 2015-16; adjusted b = 0.058; 95% CI = 0.055-0.062; P < 0.001). Declines in social distancing were more pronounced among men and in high HIV prevalence states. Increased fear of serostatus disclosure was greater among women and in high HIV prevalence states. There was significant variability in trends disaggregated by state. CONCLUSIONS During the first decade of ART scale-up in India, fear of HIV serostatus disclosure in the general population increased despite a decline in desires for social distance.
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Affiliation(s)
- Brian T Chan
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Venkatesan Chakrapani
- Centre for Sexuality and Health Research and Policy (C-SHaRP), Chennai, India
- The Humsafar Trust, Mumbai, India
| | - Alexander C Tsai
- Harvard Medical School, Boston, Massachusetts, USA
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
- Mbarara University of Science and Technology, Mbarara, Uganda
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Camlin CS, Charlebois ED, Getahun M, Akatukwasa C, Atwine F, Itiakorit H, Bakanoma R, Maeri I, Owino L, Onyango A, Chamie G, Clark TD, Cohen CR, Kwarisiima D, Kabami J, Sang N, Kamya MR, Bukusi EA, Petersen ML, V Havlir D. Pathways for reduction of HIV-related stigma: a model derived from longitudinal qualitative research in Kenya and Uganda. J Int AIDS Soc 2020; 23:e25647. [PMID: 33283986 PMCID: PMC7720278 DOI: 10.1002/jia2.25647] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION The rollout of antiretroviral therapy (ART) has been associated with reductions in HIV-related stigma, but pathways through which this reduction occurs are poorly understood. In the newer context of universal test and treat (UTT) interventions, where rapid diffusion of ART uptake takes place, there is an opportunity to understand the processes through which HIV-related stigma can decline, and how UTT strategies may precipitate more rapid and widespread changes in stigma. This qualitative study sought to evaluate how a UTT intervention influenced changes in beliefs, attitudes and behaviours related to HIV. METHODS Longitudinal qualitative in-depth semi-structured interview data were collected within a community-cluster randomized UTT trial, the Sustainable East Africa Research in Community Health (SEARCH) study, annually over three rounds (2014 to 2016) from two cohorts of adults (n = 32 community leaders, and n = 112 community members) in eight rural communities in Uganda and Kenya. Data were inductively analysed to develop new theory for understanding the pathways of stigma decline. RESULTS We present an emergent theoretical model of pathways through which HIV-related stigma may decline: internalized stigma may be reduced by two processes accelerated through the uptake and successful usage of ART: first, a reduced fear of dying and increased optimism for prolonged and healthy years of life; second, a restoration of perceived social value and fulfilment of subjective role expectations via restored physical strength and productivity. Anticipated stigma may be reduced in response to widespread engagement in HIV testing, leading to an increasing number of HIV status disclosures in a community, "normalizing" disclosure and reducing fears. Improvements in the perceived quality of HIV care lead to people living with HIV (PLHIV) seeking care in nearby facilities, seeing other known community members living with HIV, reducing isolation and facilitating opportunities for social support and "solidarity." Finally, enacted stigma may be reduced in response to the community viewing the healthy bodies of PLHIV successfully engaged in treatment, which lessens the fears that trigger enacted stigma; it becomes no longer socially normative to stigmatize PLHIV. This process may be reinforced through public health messaging and anti-discrimination laws. CONCLUSIONS Declines in HIV-related stigma appear to underway and explained by social processes accelerated by UTT efforts. Widespread implementation of UTT shows promise for reducing multiple dimensions of stigma, which is critical for improving health outcomes among PLHIV.
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Affiliation(s)
- Carol S Camlin
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
- Department of MedicineCenter for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Edwin D Charlebois
- Department of MedicineCenter for AIDS Prevention StudiesUniversity of California San FranciscoSan FranciscoCAUSA
| | - Monica Getahun
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | | | | | | | - Irene Maeri
- Kenya Medical Research InstituteNairobiKenya
| | | | | | - Gabriel Chamie
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Tamara D Clark
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Craig R Cohen
- Department of ObstetricsGynecology & Reproductive SciencesUniversity of California San FranciscoSan FranciscoCAUSA
| | | | - Jane Kabami
- Infectious Diseases Research CollaborationKampalaUganda
| | - Norton Sang
- Kenya Medical Research InstituteNairobiKenya
| | - Moses R Kamya
- Infectious Diseases Research CollaborationKampalaUganda
- School of MedicineMakerere UniversityKampalaUganda
| | | | - Maya L Petersen
- Divisions of Biostatistics and EpidemiologySchool of Public HealthUniversity of California BerkeleyBerkeleyCAUSA
| | - Diane V Havlir
- Division of HIVDepartment of MedicineInfectious Diseases, and Global MedicineUniversity of California San FranciscoSan FranciscoCAUSA
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Hosaka KRJ, Kang E, Huff J, Shaw S, Duomai S. Livelihood intervention and mental well-being among women living with HIV in Delhi. AIDS Care 2020; 33:1037-1043. [PMID: 33103920 DOI: 10.1080/09540121.2020.1837336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
ABSTRACTPoverty-alleviation programmes aimed to improved mental well-being among persons living with HIV (PLWH) in low and middle income countries have underscored the importance of understanding how and why such programmes work. We present findings from a six-month ethnographic process evaluation of Kiran, an economic livelihood programme locally designed to improve mental well-being among women affected by HIV in Delhi, India. In addition to benefits of improved economic standing, we found that supportive relationships cultivated among participants (n = 9) and with providers (n = 3) provided respite from worry about their illness and reframed what was relationally and practically possible in the context of living with HIV. In acquiring marketable craft skills with peers, participants challenged internalized scripts of being socially devalued and regained agency about their abilities to contribute to their community and support their children's immediate and future needs. We found that the benefits of Kiran weighed less on the direct alleviation of mental distress and more on the instillation of hope for their children. Our findings exemplify the importance of re-visiting a priori theories that inform interventions for PLWH and highlight the methodological merits of ethnographic approaches that underscore how theory and intervention praxis are bidirectionally informed.
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Affiliation(s)
- Kalei R J Hosaka
- John A. Burns School of Medicine, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Ezer Kang
- Department of Psychology, Howard University, Washington, DC, USA
| | - James Huff
- Human Needs and Global Resources Program, Wheaton College (IL), Wheaton, IL, USA
| | - Sheeba Shaw
- Emmanuel Hospital Association, New Delhi, India
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A total facility approach to reducing HIV stigma in health facilities: implementation process and lessons learned. AIDS 2020; 34 Suppl 1:S93-S102. [PMID: 32881798 DOI: 10.1097/qad.0000000000002585] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To describe development and implementation of a three-stage 'total facility' approach to reducing health facility HIV stigma in Ghana and Tanzania, to facilitate replication. DESIGN HIV stigma in healthcare settings hinders the HIV response and can occur during any interaction between client and staff, between staff, and within institutional processes and structures. Therefore, the design focuses on multiple socioecological levels within a health facility and targets all levels of staff (clinical and nonclinical). METHODS The approach is grounded in social cognitive theory principles and interpersonal or intergroup contact theory that works to combat stigma by creating space for interpersonal interactions, fostering empathy, and building efficacy for stigma reduction through awareness, skills, and knowledge building as well as through joint action planning for changes needed in the facility environment. The approach targets actionable drivers of stigma among health facility staff: fear of HIV transmission, awareness of stigma, attitudes, and health facility environment. RESULTS The results are the three-stage process of formative research, capacity building, and integration into facility structures and processes. Key implementation lessons learned included the importance of formative data to catalyze action and shape intervention activities, using participatory training methodologies, involving facility management throughout, having staff, and clients living with HIV facilitate trainings, involving a substantial proportion of staff, mixing staff cadres and departments in training groups, and integrating stigma-reduction into existing structures and processes. CONCLUSION Addressing stigma in health facilities is critical and this approach offers a feasible, well accepted method of doing so.
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Richterman A, Leandre F, Jerome JG, Tsai AC, Ivers LC. Mortality Over Long-term Follow-up for People With HIV Receiving Longitudinal Care and Antiretroviral Therapy in Rural Haiti. Open Forum Infect Dis 2020; 7:ofaa328. [PMID: 32851109 PMCID: PMC7442269 DOI: 10.1093/ofid/ofaa328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/05/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Deaths from HIV have fallen dramatically with the increasing availability of fully suppressive antiretroviral therapy (ART), and yet HIV remains the ninth leading cause of death in low-income countries. As more people with HIV enter care and receive ART, the focus will need to shift from expanding ART to including long-term program effectiveness and outcomes for people with HIV already engaged in care. METHODS We evaluated risk factors for mortality among people with HIV on ART receiving longitudinal care in rural Haiti. We assessed baseline characteristics using a household survey and abstracted clinical characteristics from the electronic record. We used multivariable Cox regression models to identify risk factors for mortality. RESULTS There were 464 people included in this study with a median follow-up (interquartile range [IQR]) of 69 (44-77) months, during which time 37 (8%) were lost to follow-up and 118 (25%) died (median time to death [IQR], 29 [12-53] months). After adjustment, poverty (adjusted hazard ratio [AHR], 1.12 per 10-percentage point increased probability; 95% CI, 1.01-1.24) and single marital status (AHR, 1.59; 95% CI, 1.08-2.36) were associated with increased mortality. Age (AHR, 0.78 per 10-year increase; 95% CI, 0.64-0.94), role function quality of life (AHR, 0.75 per quintile increase; 95% CI, 0.62-0.90), and CD4 count (AHR, 0.66 per 100 cells/μL; 95% CI, 0.58-0.75) were associated with decreased mortality. CONCLUSIONS Poverty, marital status, and quality of life were associated with mortality. Social protection should be evaluated as a strategy to reduce mortality for people with HIV in concert with increasing access to ART.
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Affiliation(s)
- Aaron Richterman
- Division of Infectious Diseases, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fernet Leandre
- Zanmi Lasante/Partners In Health, Cange, Haiti
- Division of Global Health Equity, Brigham and Women Hospital, Boston, Massachusetts, USA
| | | | - Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Louise C Ivers
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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McDonough A, Weiser SD, Daniel A, Weke E, Wekesa P, Burger R, Sheira L, Bukusi EA, Cohen CR. "When I Eat Well, I Will Be Healthy, and the Child Will Also Be Healthy": Maternal Nutrition among HIV-Infected Women Enrolled in a Livelihood Intervention in Western Kenya. Curr Dev Nutr 2020; 4:nzaa032. [PMID: 32270133 PMCID: PMC7127924 DOI: 10.1093/cdn/nzaa032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Food insecurity remains a major obstacle to achieving health and well-being for individuals living with HIV in western Kenya. Studies have shown that pregnant women are vulnerable to experiencing food insecurity worldwide, with significant consequences for both maternal and child health. The Shamba Maisha cluster randomized controlled trial in western Kenya (which means "farming for life" in Swahili) tested the effects of a multisectoral livelihood intervention consisting of agricultural and finance trainings, farm inputs, and a loan on health and food security among 746 farmers living with HIV in Kisumu, Homa Bay, and Migori Counties. OBJECTIVES We conducted a qualitative substudy within the Shamba Maisha trial to understand the experiences and perspectives of pregnant women living with HIV enrolled in the trial. METHODS Thirty women who had experienced a pregnancy during the Shamba Maisha study period, comprising 20 women in the intervention arm and 10 women in the control arm, completed in-depth interviews using a semistructured interview guide. RESULTS Intervention participants interviewed noted improvements in maternal nutrition compared with previous pregnancies, which they attributed to the livelihood intervention. Key identified pathways to improved nutrition included improved access to vegetables, increased variety of diet through vegetable sales, and improved nutritional awareness. Women in the intervention arm also perceived increased weight gain compared with prior pregnancies and increased strength and energy throughout pregnancy. CONCLUSIONS Livelihood interventions represent a promising solution to alleviate food insecurity for pregnant women in order to improve maternal and child health outcomes.This trial was registered at clinicaltrials.gov as NCT02815579.
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Affiliation(s)
- Annie McDonough
- San Francisco School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sheri D Weiser
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Afkera Daniel
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elly Weke
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Pauline Wekesa
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rachel Burger
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Lila Sheira
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Craig R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
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Hatcher A, Lemus Hofstedler L, Doria K, Dworkin S, Weke E, Conroy A, Bukusi E, Cohen C, Weiser S. Mechanisms and perceived mental health changes after a livelihood intervention for HIV-positive Kenyans: Longitudinal, qualitative findings. Transcult Psychiatry 2020; 57:124-139. [PMID: 31242065 PMCID: PMC6930985 DOI: 10.1177/1363461519858446] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
While food insecurity and poverty worsen mental health outcomes among people living with HIV/AIDS (PLHIV), few intervention studies have targeted poverty and food insecurity as a way to improve mental health. Among HIV-positive patients, addressing such upstream determinants may prove crucial to ensure better mental health and HIV clinical outcomes. We integrated longitudinal, qualitative research into a randomized trial of a livelihood intervention to understand processes and mechanisms for how the intervention may affect mental health among HIV-infected Kenyan adults. In-depth interviews were conducted with intervention participants (n = 45) and control participants (n = 9) at two time-points (after intervention start and upon intervention end). Interviews (n = 85) were translated, double-coded, and analyzed thematically using an inductive-deductive team approach. Participants reported numerous mental health improvements post-intervention including reduced stress, fewer symptoms of anxiety, improved mood, lower depressive symptoms, fewer repetitive and ruminating thoughts, and more hopefulness for the future. Improvements in mental health appear to occur via several mechanisms including: 1) better food security and income; 2) increased physical activity and ability to create fruitful routines around farm work; and, 3) improved sense of self as an active member of the community. Qualitative, longitudinal interviews may help identify intervention mechanisms for improved mental health, but additional research is required to confirm self-reports of mental health changes. These findings suggest that livelihood interventions may improve mental health in multi-faceted ways, and help PLHIV better integrate with their communities. Trial registered at ClinicalTrials.gov: NCT01548599.
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Affiliation(s)
- A.M Hatcher
- University of the Witwatersrand and an Honorary Researcher at the University of California, San Francisco
| | | | | | - S. Dworkin
- University of Washington Bothell School of Nursing and Health Studies
| | - E. Weke
- Kenya Medical Research Institute (KEMRI)
| | - A. Conroy
- Center for AIDS Prevention Studies at the University of California San Francisco
| | - E. Bukusi
- Kenya Medical Research Institute (KEMRI), University of Washington and University of California San Francisco
| | - C.R Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences at the University of California San Francisco (UCSF) and University of California Global Health Institute (UCGHI)
| | - S.D. Weiser
- Division of HIV, Infectious Disease and Global Medicine at UCSF
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Rasmussen JD, Kakuhikire B, Baguma C, Ashaba S, Cooper-Vince CE, Perkins JM, Bangsberg DR, Tsai AC. Portrayals of mental illness, treatment, and relapse and their effects on the stigma of mental illness: Population-based, randomized survey experiment in rural Uganda. PLoS Med 2019; 16:e1002908. [PMID: 31539373 PMCID: PMC6754129 DOI: 10.1371/journal.pmed.1002908] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 08/20/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Mental illness stigma is a fundamental barrier to improving mental health worldwide, but little is known about how to durably reduce it. Understanding of mental illness as a treatable medical condition may influence stigmatizing beliefs, but available evidence to inform this hypothesis has been derived solely from high-income countries. We embedded a randomized survey experiment within a whole-population cohort study in rural southwestern Uganda to assess the extent to which portrayals of mental illness treatment effectiveness influence personal beliefs and perceived norms about mental illness and about persons with mental illness. METHODS AND FINDINGS Study participants were randomly assigned to receive a vignette describing a typical woman (control condition) or one of nine variants describing a different symptom presentation (suggestive of schizophrenia, bipolar, or major depression) and treatment course (no treatment, treatment with remission, or treatment with remission followed by subsequent relapse). Participants then answered questions about personal beliefs and perceived norms in three domains of stigma: willingness to have the woman marry into their family, belief that she is receiving divine punishment, and belief that she brings shame on her family. We used multivariable Poisson and ordered logit regression models to estimate the causal effect of vignette treatment assignment on each stigma-related outcome. Of the participants randomized, 1,355 were successfully interviewed (76%) from November 2016 to June 2018. Roughly half of respondents were women (56%), half had completed primary school (57%), and two-thirds were married or cohabiting (64%). The mean age was 42 years. Across all types of mental illness and treatment scenarios, relative to the control vignette (22%-30%), substantially more study participants believed the woman in the vignette was receiving divine punishment (31%-54%) or believed she brought shame on her family (51%-73%), and most were unwilling to have her marry into their families (80%-88%). In multivariable Poisson regression models, vignette portrayals of untreated mental illness, relative to the control condition, increased the risk that study participants endorsed stigmatizing personal beliefs about mental illness and about persons with mental illness, irrespective of mental illness type (adjusted risk ratios [ARRs] varied from 1.7-3.1, all p < 0.001). Portrayals of effectively treated mental illness or treatment followed by subsequent relapse also increased the risk of responses indicating stigmatizing personal beliefs relative to control (ARRs varied from 1.5-3.0, all p < 0.001). The magnitudes of the estimates suggested that portrayals of initially effective treatment (whether followed by relapse or not) had little moderating influence on stigmatizing responses relative to vignettes portraying untreated mental illness. Responses to questions about perceived norms followed similar patterns. The primary limitations of this study are that the vignettes may have omitted context that could have influenced stigma and that generalizability beyond rural Uganda may be limited. CONCLUSIONS In a population-based, randomized survey experiment conducted in rural southwestern Uganda, portrayals of effectively treated mental illness did not appear to reduce endorsement of stigmatizing beliefs about mental illness or about persons with mental illness. These findings run counter to evidence from the United States. Further research is necessary to understand the relationship between mental illness treatment and stigmatizing attitudes in Uganda and other countries worldwide. TRIAL REGISTRATION The experimental procedures for this study were registered with ClinicalTrials.gov as "Measuring Beliefs and Norms About Persons With Mental Illness" (NCT03656770).
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Affiliation(s)
- Justin D. Rasmussen
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Duke University, Durham, North Carolina, United States of America
| | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | - Jessica M. Perkins
- Peabody College, Vanderbilt University, Nashville, Tennessee, United States of America
| | - David R. Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda
- Oregon Health Sciences University–Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Alexander C. Tsai
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
- Harvard Medical School, Boston, Massachusetts, United States of America
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Manne-Goehler J, Rohr J, Montana L, Siedner M, Harling G, Gómez-Olivé FX, Geldsetzer P, Wagner R, Wiesner L, Kahn K, Tollman S, Bärnighausen TW. ART Denial: Results of a Home-Based Study to Validate Self-reported Antiretroviral Use in Rural South Africa. AIDS Behav 2019; 23:2072-2078. [PMID: 30523490 DOI: 10.1007/s10461-018-2351-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
There is increasing interest in home based testing and treatment of HIV to expand access to treatment in sub-Saharan Africa. Such programs rely on self-reported HIV history and use of antiretroviral therapy (ART). However, the accuracy of self-reported ART use in community settings is not well described. In this study, we compared self-reported ART (SR-ART) use in a home based survey against biological exposure to ART (BE-ART), in a population study of older adults in South Africa. Health and Aging in Africa: a Longitudinal Study of an INDEPTH community in South Africa (HAALSI) is a cohort of adults aged 40 +. The baseline home-based interview included self-reported HIV status and ART use. All participants also underwent biological testing for HIV antibodies, viral load and exposure to emtricitabine (FTC) or lamivudine (3TC), which are included in all first-line and second-line ART regimens in the public-sector South African HIV program. We calculated the performance characteristics for SR-ART compared to BE-ART and fit multivariable logistic regression models to identify correlates of invalid SR-ART responses. Of 4560 HAALSI participants with a valid HIV test result available, 1048 (23%) were HIV-positive and 734 [70% of people living with HIV (PLWH)] were biologically validated ART users (BE-ART). The sensitivity of SR-ART use was 64% (95% CI 61-68%) and the specificity was 94% (95% CI 91-96%); the positive predictive value (PPV) was 96% (95% CI 94-98%) and negative predictive value (NPV) was 52% (95% CI 48-56%). We found no sociodemographic predictors of accurate SR-ART use. Over one in three individuals with detectable ART in their blood denied current ART use during a home-based interview. These results demonstrate ongoing stigma related to HIV and its treatment, and have important implications for community health worker programs, clinical programs, and research studies planning community-based ART initiation in the region.
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Pantelic M, Sprague L, Stangl AL. It's not "all in your head": critical knowledge gaps on internalized HIV stigma and a call for integrating social and structural conceptualizations. BMC Infect Dis 2019; 19:210. [PMID: 30832613 PMCID: PMC6399894 DOI: 10.1186/s12879-019-3704-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/09/2019] [Indexed: 01/20/2023] Open
Abstract
Background Internalized HIV stigma is a public health concern as it can compromise HIV prevention, care and treatment. This paper has two aims. First, it highlights the urgent need for research evidence on internalized HIV stigma based on critical knowledge gaps. Here, critical knowledge gaps were identified based on most up-to-date systematic review-level evidence on internalized stigma related to HIV and mental health difficulties. Secondly, the paper calls for a shift in focus of internalized HIV stigma research, one that moves beyond psychological frameworks to integrate social, structural and intersectional conceptualizations of stigma. This part of the paper reviews the evolution of stigma theory since Goffman’s 1963 seminal work - which defined stigma - to present. Main text Despite studies consistently suggesting that internalized HIV stigma is more prevalent than enacted stigma, there is little evidence of well-established programs to address it. In addition to this, considerable gaps in basic knowledge about the drivers of internalized HIV stigma hamper the development of an evidence-based response to the problem. The limited intervention and epidemiological research on the topic treats internalized HIV stigma as a purely psychological phenomenon. The second part of the paper provides arguments for studying internalized HIV stigma as a function of social and structural forces: (1) Individual-level interventions for internalized HIV stigma are rooted in out-dated theoretical assumptions; (2) From an ethics point of view, it could be argued that individual-level interventions rely on a victim-centric approach to a public health problem; (3) Social and structural approaches to internalized HIV stigma must be explored due to the high opportunity cost associated with small-scale individual-level interventions. Conclusions Critical gaps in intervention and epidemiological research in internalized HIV stigma remain. There has been an absence of a shared, sound theoretical understanding of internalized HIV stigma as a manifestation of social and structural factors. This commentary sought to stimulate a dialogue to remedy this absence. Future research should take into account ethical considerations, the evolution of stigma theory over the past five decades, intersectionality and opportunity cost when framing hypotheses, developing theories of change and designing interventions.
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Affiliation(s)
- Marija Pantelic
- Frontline AIDS, Secretariat, Preece House, 91-101 Davigdor Rd, Brighton, Hove, BN3 1RE, UK. .,Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 -37 Wellington Square, Oxford, OX1 2ER, UK.
| | - Laurel Sprague
- Global Network of People Living with HIV (GNP+), Eerste Helmersstraat 17 B3 I, 1054 CX, Amsterdam, The Netherlands
| | - Anne L Stangl
- Department of Global Health, Youth and Development, The International Center for Research on Women, 1120 20th St. NW Suite 500N, Washington, DC, 20036, USA
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Idemudia ES, Olasupo MO, Modibo MW. Stigma and chronic illness: A comparative study of people living with HIV and/or AIDS and people living with hypertension in Limpopo Province, South Africa. Curationis 2018; 41:e1-e5. [PMID: 30456983 PMCID: PMC6244151 DOI: 10.4102/curationis.v41i1.1879] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 07/27/2018] [Accepted: 08/02/2018] [Indexed: 01/15/2023] Open
Abstract
Background Stigma among people with chronic illnesses exists, preventing many sufferers from presenting for treatment especially in South Africa. Objectives This study compared stigma experiences of people living with human immunodeficiency virus and/or acquired immunodeficiency syndrome (HIV and/or AIDS) (PLWHA) and people living with hypertension (PLWHPT) in Limpopo Province of South Africa. Method Using a cross-sectional design, 600 participants (300 PLWHA with mean age of 31 years, standard deviation of 8.2; and 300 PLWHPT with age of 55 years, standard deviation of 8.1) were purposefully sampled at HIV and/or AIDS and hypertension outpatient clinics. The perceived stigma of AIDS scale was used to assess stigma in the HIV and/or AIDS sample while the adapted version was used to assess stigma in PLWHPT. Data were analysed using independent t-test. Results Results indicated that PLWHA experienced significantly higher enacted stigma (t(598) = −11.79, p < 0.001) as compared to PLWHPT. However, PLWHPT experienced significantly higher internalised stigma (t(598) = 37.56, p < 0.001) and perceived stigma (t(598) = 41.71, p < 0.001) than PLWHA. Conclusion Stigma among people with chronic illnesses is existent. The stigma type is, however, dependent on the nature of the illness. Stigma reduction interventions among these populations are indicated.
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Affiliation(s)
- Erhabor S Idemudia
- Population and Health Research Entity, Faculty of Humanities, North-West University.
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Earnshaw VA, Bogart LM, Laurenceau J, Chan BT, Maughan‐Brown BG, Dietrich JJ, Courtney I, Tshabalala G, Orrell C, Gray GE, Bangsberg DR, Katz IT. Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator. J Int AIDS Soc 2018; 21:e25198. [PMID: 30362662 PMCID: PMC6202800 DOI: 10.1002/jia2.25198] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 10/02/2018] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Cross-sectional evidence suggests that internalized HIV stigma is associated with lower likelihoods of antiretroviral therapy (ART) initiation and HIV-1 RNA suppression among people living with HIV (PLWH). This study examined these associations with longitudinal data spanning the first nine months following HIV diagnosis and explored whether avoidant coping mediates these associations. METHODS Longitudinal data were collected from 398 South African PLWH recruited from testing centres in 2014 to 2015. Self-report data, including internalized stigma and avoidant coping (denying and distracting oneself from stressors), were collected one week and three months following HIV diagnosis. ART initiation at six months and HIV-1 RNA at nine months were extracted from the South Africa National Health Laboratory Service database. Two path analyses were estimated, one testing associations between internalized stigma, avoidant coping and ART initiation, and the other testing associations between internalized stigma, avoidant coping and HIV-1 RNA suppression. RESULTS Participants were 36 years old, on average, and 63% identified as female, 18% as Zulu and 65% as Xhosa. The two path models fit the data well (ART initiation outcome: X2 (7) = 8.14, p = 0.32; root mean square error of approximation (RMSEA) = 0.02; comparative fit index (CFI) = 0.92; HIV-1 RNA suppression outcome: X2 (7) = 6.58, p = 0.47; RMSEA = 0.00; CFI = 1.00). In both models, internalized stigma one week after diagnosis was associated with avoidant coping at three months, controlling for avoidant coping at one week. In turn, avoidant coping at three months was associated with lower likelihood of ART initiation at six months in the first model and lower likelihood of HIV-1 RNA suppression at nine months in the second model. Significant indirect effects were observed between internalized stigma with ART non-initiation and unsuppressed HIV-1 RNA via the mediator of avoidant coping. CONCLUSIONS Internalized stigma experienced soon after HIV diagnosis predicted lower likelihood of ART initiation and HIV-1 RNA suppression over the first year following HIV diagnosis. Avoidant coping played a role in these associations, suggesting that PLWH who internalize stigma engage in greater avoidant coping, which in turn worsens medication- and health-related outcomes. Interventions are needed to address internalized stigma and avoidant coping soon after HIV diagnosis to enhance treatment efforts during the first year after HIV diagnosis.
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Affiliation(s)
- Valerie A Earnshaw
- Department of Human Development and Family SciencesUniversity of DelawareNewarkDEUSA
| | | | | | - Brian T Chan
- Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Brendan G Maughan‐Brown
- Southern Africa Labour and Development Research UnitUniversity of Cape TownRondeboschCape TownSouth Africa
| | - Janan J Dietrich
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Ingrid Courtney
- Desmond Tutu HIV Centre, IDM and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Gugulethu Tshabalala
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Catherine Orrell
- Desmond Tutu HIV Centre, IDM and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Glenda E Gray
- Perinatal HIV Research UnitFaculty of Health SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
- South African Medical Research CouncilCape TownSouth Africa
| | - David R Bangsberg
- Oregon Health & Science University‐Portland State University School of Public HealthPortlandORUSA
| | - Ingrid T Katz
- Department of MedicineBrigham and Women's HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
- Center for Global HealthMassachusetts General HospitalBostonMAUSA
- Harvard Global Health InstituteCambridgeMAUSA
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Nyblade L, Srinivasan K, Mazur A, Raj T, Patil DS, Devadass D, Radhakrishna K, Ekstrand ML. HIV Stigma Reduction for Health Facility Staff: Development of a Blended- Learning Intervention. Front Public Health 2018; 6:165. [PMID: 29977887 PMCID: PMC6021510 DOI: 10.3389/fpubh.2018.00165] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/17/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction: The effect of stigma on health and health inequity is increasingly recognized. While many medical conditions trigger stigmatization, the negative effects of HIV stigma are particularly well documented. HIV stigma undermines access, uptake, and adherence to both HIV prevention and treatment. People living with HIV face stigma in all aspects of their daily lives; however, stigma in the health system is particularly detrimental. A key component for health facility stigma-reduction interventions is participatory training of staff, often through several days of in-person training. Though this approach shows promise, it is time intensive and poses challenges for busy health facilities. In response, the DriSti study has developed a brief blended-learning approach to stigma reduction in Karnataka State, India. This paper describes the process and final content of the intervention development. The intervention is currently being tested. Final evaluation results will be published upon study completion. Methods: Grounded in behavior change strategies based on social cognitive theory principles that stress the importance of combining interpersonal interactions with specific strategies that promote behavior change, we used a three-phase approach to intervention development: (1) content planning—review of existing participatory stigma-reduction training activities; (2) story boarding—script development and tablet content production; and (3) pilot testing of tablet and in-person session materials. Results: The final intervention curriculum consists of three sessions. Two initial self-administered tablet sessions focus on stigma awareness, attitudes, fears of HIV transmission, and use of standard precautions. The third small group session covers the same material but includes skill building through role-play and testimony by a person living with HIV. A study team member administers the tablet sessions, explains the process, and is present throughout to answer questions. Conclusion: This paper describes the theoretical underpinning and process of developing the blended-learning curriculum content, and practical lessons learned.The approach covers three key drivers of HIV stigma—stigma awareness, fear of HIV transmission, and attitudes. Developing video content for the self-directed learning is complex, requires a diverse set of people and skills, and presents unexpected opportunities for stigma reduction. Co-facilitation of the in-person session by someone living with HIV is a critical component.
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Affiliation(s)
- Laura Nyblade
- Global Health Division, International Development Group, RTI International, Washington, DC, United States
| | | | - Amanda Mazur
- Department of Medicine, Center for AIDS Prevention Studies, San Francisco, CA, United States
| | - Tony Raj
- St. Johns Research Institute, Bangalore, India
| | | | | | | | - Maria L Ekstrand
- St. Johns Research Institute, Bangalore, India.,Department of Medicine, Center for AIDS Prevention Studies, San Francisco, CA, United States
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Patient-Initiated Repackaging of Antiretroviral Therapy, Viral Suppression and Drug Resistance. AIDS Behav 2018; 22:1671-1678. [PMID: 28185021 DOI: 10.1007/s10461-017-1721-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Patient-initiated repackaging of antiretroviral therapy (ART) refers to removal of ART medications from their original manufacturer's containers, and putting them into alternative containers. This behavior may be triggered by stigma associated with HIV infection, and may impact patient outcomes. We assessed association between patient initiated repackaging of ART and failure to achieve viral suppression (FVS) in a sample of 450 HIV-infected adults (≥8 years) on first line ART for ≥6 months. FVS was defined as a plasma HIV RNA level ≥400 copies/mL. A total of 197 (43.7%) patients reported repackaging their ART medications. One hundred ninety-one patients (42.4%) failed to suppress and FVS was associated with medication repackaging [adjusted odds ratio (aOR), 2.2; 95% CI 1.4-3.3.] Adherence to ART was also associated with FVS (aOR; 0.4; 95% CI 0.2-0.6.). Benefits of retaining drugs in their original packaging along with adherence to ART should be emphasized to reduce the risk of FVS.
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Process Evaluation of a Randomized Controlled Trial of Group Support Psychotherapy for Depression Treatment Among People with HIV/AIDS in Northern Uganda. Community Ment Health J 2017; 53:991-1004. [PMID: 28317086 PMCID: PMC5664415 DOI: 10.1007/s10597-017-0129-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/07/2017] [Indexed: 12/28/2022]
Abstract
We describe the process evaluation for a randomized controlled trial that compared group support psychotherapy (GSP) with group HIV education for treatment of depression among people with HIV. Process data were obtained using mixed methods. Variables evaluated were indicators of feasibility and acceptability; causal mediating processes and contextual influences. GSP was feasible and acceptable. Potential mediating variables between GSP and reduction of depression were improved emotional and social support, better coping strategies, and pursuit of livelihoods. Culturally sensitive intervention content facilitated intervention delivery. These data complement the trial outcomes, and may provide a contextualized description of how GSP treats depression.
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Personal contact with HIV-positive persons is associated with reduced HIV-related stigma: cross-sectional analysis of general population surveys from 26 countries in sub-Saharan Africa. J Int AIDS Soc 2017; 20:21395. [PMID: 28362067 PMCID: PMC5461118 DOI: 10.7448/ias.20.1.21395] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Introduction: HIV-related stigma hampers treatment and prevention efforts worldwide. Effective interventions to counter HIV-related stigma are greatly needed. Although the “contact hypothesis” suggests that personal contact with persons living with HIV (PLHIV) may reduce stigmatizing attitudes in the general population, empirical evidence in support of this hypothesis is lacking. Our aim was to estimate the association between personal contact with PLHIV and HIV-related stigma among the general population of sub-Saharan Africa. Methods: Social distance and anticipated stigma were operationalized using standard HIV-related stigma questions contained in the Demographic and Health Surveys and AIDS Indicator Surveys of 26 African countries between 2003 and 2008. We fitted multivariable logistic regression models with country-level fixed effects, specifying social distance as the dependent variable and personal contact with PLHIV as the primary explanatory variable of interest. Results: We analyzed data from 206,717 women and 91,549 men living in 26 sub-Saharan African countries. We estimated a statistically significant negative association between personal contact with PLHIV and desires for social distance (adjusted odds ratio [AOR] = 0.80; p < 0.001; 95% Confidence Interval [CI], 0.73–0.88). In a sensitivity analysis, a similar finding was obtained with a model that used a community-level variable for personal contact with PLHIV (AOR = 0.92; p < 0.001; 95% CI, 0.89–0.95). Conclusions: Personal contact with PLHIV was associated with reduced desires for social distance among the general population of sub-Saharan Africa. More contact interventions should be developed and tested to reduce the stigma of HIV.
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Denison JA, Pettifor A, Mofenson LM, Kasedde S, Marcus R, Konayuma KJ, Koboto K, Ngcobo ML, Ndleleni N, Pulerwitz J, Kerrigan D. Youth engagement in developing an implementation science research agenda on adolescent HIV testing and care linkages in sub-Saharan Africa. AIDS 2017; 31 Suppl 3:S195-S201. [PMID: 28665877 PMCID: PMC5497774 DOI: 10.1097/qad.0000000000001509] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The importance of youth engagement in designing, implementing and evaluating programs has garnered more attention as international initiatives seek to address the HIV crisis among this population. Adolescents, however, are not often included in HIV implementation science research and have not had opportunities to contribute to the development of HIV-related research agendas. Project Supporting Operational AIDS Research (SOAR), a United States Agency for International Development-funded global operations research project, involved youth living with HIV in a meeting to develop a strategic implementation science research agenda to improve adolescent HIV care continuum outcomes, including HIV testing and counseling (HTC) and linkage to care. METHODS Project SOAR convened a 2-day meeting of 50 experts, including four youth living with HIV. Participants examined the literature, developed research questions, and voted to prioritize these questions for the implementation science research agenda. This article presents the process of involving youth, how they shaped the course of discussions, and the resulting priority research gaps identified at the meeting. RESULTS Youth participation influenced working group discussions and the development of the implementation science agenda. Research gaps identified included how to engage vulnerable adolescents, determining the role that stigma, peers, and self-testing have in shaping adolescent HTC behaviors, and examining the costs of different HTC and linkage to care strategies. CONCLUSION The meeting participants developed the research agenda to guide future implementation science research to improve HIV outcomes among adolescents in sub-Saharan Africa. This process highlighted the importance of youth in shaping implementation science research agendas and the need for greater youth engagement.
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Affiliation(s)
- Julie A. Denison
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Audrey Pettifor
- University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Lynne M. Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, District of Columbia
| | - Susan Kasedde
- United Nations Children's Fund, New York, New York, USA
| | - Rebecca Marcus
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Mmangaliso Luyanda Ngcobo
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Nokuthula Ndleleni
- The Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Deanna Kerrigan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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HIV stigma trends in the general population during antiretroviral treatment expansion: analysis of 31 countries in sub-Saharan Africa, 2003-2013. J Acquir Immune Defic Syndr 2017; 72:558-64. [PMID: 27035888 DOI: 10.1097/qai.0000000000001011] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND HIV-related stigma is associated with increased risk-taking behavior, reduced uptake of HIV testing, and decreased adherence to antiretroviral therapy (ART). Although ART scale-up may reduce HIV-related stigma, the extent to which levels of stigma in the general population have changed during the era of ART scale-up in sub-Saharan Africa is unknown. METHODS Social distance and anticipated stigma were operationalized using standard HIV-related stigma questions contained in the Demographic and Health Surveys and AIDS Indicator Surveys of 31 African countries between 2003 and 2013. We fitted multivariable linear regression models with cluster-correlated robust standard errors and country fixed effects, specifying social distance or anticipated stigma as the dependent variable and year as the primary explanatory variable of interest. RESULTS We estimated a statistically significant negative association between year and desires for social distance (b = -0.020; P < 0.001; 95% confidence interval: -0.026 to -0.015) but a statistically significant positive association between year and anticipated stigma (b = 0.023; P < 0.001; 95% confidence interval: 0.018 to 0.027). In analyses stratified by HIV prevalence above or below the sample median, declines in social distancing over time were more pronounced among countries with a higher HIV prevalence. CONCLUSIONS Concomitant with ART scale-up in sub-Saharan Africa, anticipated stigma in the general population increased despite a decrease in social distancing toward people living with HIV. Although ART scale-up may help reduce social distancing toward people living with HIV, particularly in high-prevalence countries, other interventions targeting symbolic or instrumental concerns about HIV may be needed.
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Turan B, Hatcher AM, Weiser SD, Johnson MO, Rice WS, Turan JM. Framing Mechanisms Linking HIV-Related Stigma, Adherence to Treatment, and Health Outcomes. Am J Public Health 2017; 107:863-869. [PMID: 28426316 DOI: 10.2105/ajph.2017.303744] [Citation(s) in RCA: 293] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We present a conceptual framework that highlights how unique dimensions of individual-level HIV-related stigma (perceived community stigma, experienced stigma, internalized stigma, and anticipated stigma) might differently affect the health of those living with HIV. HIV-related stigma is recognized as a barrier to both HIV prevention and engagement in HIV care, but little is known about the mechanisms through which stigma leads to worse health behaviors or outcomes. Our conceptual framework posits that, in the context of intersectional and structural stigmas, individual-level dimensions of HIV-related stigma operate through interpersonal factors, mental health, psychological resources, and biological stress pathways. A conceptual framework that encompasses recent advances in stigma science can inform future research and interventions aiming to address stigma as a driver of HIV-related health.
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Affiliation(s)
- Bulent Turan
- Bulent Turan and Whitney S. Rice are with the Department of Psychology, University of Alabama at Birmingham. Abigail M. Hatcher and Mallory O. Johnson are with the Department of Medicine, University of California, San Francisco. Sheri D. Weiser is with the Division of HIV, Infectious Disease and Global Medicine, University of California, San Francisco. Janet M. Turan is with the Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham
| | - Abigail M Hatcher
- Bulent Turan and Whitney S. Rice are with the Department of Psychology, University of Alabama at Birmingham. Abigail M. Hatcher and Mallory O. Johnson are with the Department of Medicine, University of California, San Francisco. Sheri D. Weiser is with the Division of HIV, Infectious Disease and Global Medicine, University of California, San Francisco. Janet M. Turan is with the Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham
| | - Sheri D Weiser
- Bulent Turan and Whitney S. Rice are with the Department of Psychology, University of Alabama at Birmingham. Abigail M. Hatcher and Mallory O. Johnson are with the Department of Medicine, University of California, San Francisco. Sheri D. Weiser is with the Division of HIV, Infectious Disease and Global Medicine, University of California, San Francisco. Janet M. Turan is with the Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham
| | - Mallory O Johnson
- Bulent Turan and Whitney S. Rice are with the Department of Psychology, University of Alabama at Birmingham. Abigail M. Hatcher and Mallory O. Johnson are with the Department of Medicine, University of California, San Francisco. Sheri D. Weiser is with the Division of HIV, Infectious Disease and Global Medicine, University of California, San Francisco. Janet M. Turan is with the Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham
| | - Whitney S Rice
- Bulent Turan and Whitney S. Rice are with the Department of Psychology, University of Alabama at Birmingham. Abigail M. Hatcher and Mallory O. Johnson are with the Department of Medicine, University of California, San Francisco. Sheri D. Weiser is with the Division of HIV, Infectious Disease and Global Medicine, University of California, San Francisco. Janet M. Turan is with the Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham
| | - Janet M Turan
- Bulent Turan and Whitney S. Rice are with the Department of Psychology, University of Alabama at Birmingham. Abigail M. Hatcher and Mallory O. Johnson are with the Department of Medicine, University of California, San Francisco. Sheri D. Weiser is with the Division of HIV, Infectious Disease and Global Medicine, University of California, San Francisco. Janet M. Turan is with the Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham
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Masa R, Chowa G, Nyirenda V. Prevalence and Predictors of Food Insecurity among People Living with HIV Enrolled in Antiretroviral Therapy and Livelihood Programs in Two Rural Zambian Hospitals. Ecol Food Nutr 2017; 56:256-276. [PMID: 28418728 DOI: 10.1080/03670244.2017.1311256] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The objective of this study was to examine the prevalence and predictors of food insecurity among people living with HIV (PLHIV) in two rural communities in Zambia. A cross-sectional sample of 101 PLHIV was surveyed using the Household Food Insecurity Access Scale. In multivariable linear regression models, income, household possessions, and perceived coping strategies were significantly associated with decreased food insecurity. Debt and perceived mental distress were significantly associated with increased food insecurity. Programs that tackle economic disadvantage and its adverse effect on stress may be an appropriate strategy to improve food security of PLHIV in low-resource communities.
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Affiliation(s)
- Rainier Masa
- a Global Social Development Innovations , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA.,b School of Social Work , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
| | - Gina Chowa
- a Global Social Development Innovations , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA.,b School of Social Work , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
| | - Victor Nyirenda
- a Global Social Development Innovations , University of North Carolina at Chapel Hill , Chapel Hill , North Carolina , USA
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Sharma M, Barnabas RV, Celum C. Community-based strategies to strengthen men's engagement in the HIV care cascade in sub-Saharan Africa. PLoS Med 2017; 14:e1002262. [PMID: 28399122 PMCID: PMC5388461 DOI: 10.1371/journal.pmed.1002262] [Citation(s) in RCA: 144] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Monica Sharma and colleagues discuss evidence-based approaches to improving HIV services for men in sub-Saharan Africa.
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Affiliation(s)
- Monisha Sharma
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | - Ruanne V. Barnabas
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- School of Medicine, University of Washington, Seattle, Washington, United States of America
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Connie Celum
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- School of Medicine, University of Washington, Seattle, Washington, United States of America
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Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
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Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
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Hargreaves JR, Busza J, Mushati P, Fearon E, Cowan FM. Overlapping HIV and sex-work stigma among female sex workers recruited to 14 respondent-driven sampling surveys across Zimbabwe, 2013. AIDS Care 2016; 29:675-685. [PMID: 27998178 DOI: 10.1080/09540121.2016.1268673] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
HIV stigma can inhibit uptake of HIV testing and antiretroviral therapy as well as negatively affect mental health. Efforts to reduce discrimination against people living with HIV (LWH) have contributed to greater acceptance of the infection. Female sex workers (FSW) LWH may experience overlapping stigma due to both their work and HIV status, although this is poorly understood. We examined HIV and sex-work stigma experienced by FSW LWH in Zimbabwe. Using the SAPPH-IRe cluster-randomised trial baseline survey, we analysed the data from 1039 FSW self-reporting HIV. The women were recruited in 14 sites using respondent-driven sampling. We asked five questions to assess internalised and experienced stigma related to working as a sex worker, and the same questions were asked in reference to HIV. Among all FSW, 91% reported some form of sex-work stigma. This was not associated with sociodemographic or sex-work characteristics. Rates of sex-work stigma were higher than those of HIV-related stigma. For example, 38% reported being "talked badly about" for LWH compared with 77% for their involvement in sex work. Those who reported any sex-work stigma also reported experiencing more HIV stigma compared to those who did not report sex-work stigma, suggesting a layering effect. FSW in Zimbabwe experience stigma for their role as "immoral" women and this appears more prevalent than HIV stigma. As HIV stigma attenuates, other forms of social stigma associated with the disease may persist and continue to pose barriers to effective care.
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Affiliation(s)
- J R Hargreaves
- a Department of Social and Environmental Health Research , London School of Hygiene and Tropical Medicine , London , UK
| | - J Busza
- b Department of Population Health , London School of Hygiene and Tropical Medicine , London , UK
| | - P Mushati
- c Centre for Sexual Health and HIV/AIDS Research Zimbabwe , Harare , Zimbabwe
| | - E Fearon
- a Department of Social and Environmental Health Research , London School of Hygiene and Tropical Medicine , London , UK
| | - F M Cowan
- c Centre for Sexual Health and HIV/AIDS Research Zimbabwe , Harare , Zimbabwe.,d Department of Infection and Population Health , University College London , London , UK
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Kakuhikire B, Suquillo D, Atuhumuza E, Mushavi R, Perkins JM, Venkataramani AS, Weiser SD, Bangsberg DR, Tsai AC. A livelihood intervention to improve economic and psychosocial well-being in rural Uganda: Longitudinal pilot study. SAHARA J 2016; 13:162-9. [PMID: 27619011 PMCID: PMC5642427 DOI: 10.1080/17290376.2016.1230072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
HIV and poverty are inextricably intertwined in sub-Saharan Africa. Economic and livelihood intervention strategies have been suggested to help mitigate the adverse economic effects of HIV, but few intervention studies have focused specifically on HIV-positive persons. We conducted three pilot studies to assess a livelihood intervention consisting of an initial orientation and loan package of chickens and associated implements to create poultry microenterprises. We enrolled 15 HIV-positive and 22 HIV-negative participants and followed them for up to 18 months. Over the course of follow-up, participants achieved high chicken survival and loan repayment rates. Median monthly income increased, and severe food insecurity declined, although these changes were not statistically significant (P-values ranged from 0.11 to 0.68). In-depth interviews with a purposive sample of three HIV-positive participants identified a constellation of economic and psychosocial benefits, including improved social integration and reduced stigma.
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Affiliation(s)
- Bernard Kakuhikire
- MBA, is Senior Lecturer and Director of the Institute of Management Sciences, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Diego Suquillo
- MIB, is a resident tutor at Quincy House, Harvard College, Cambridge, MA, USA
| | - Elly Atuhumuza
- MSc, is a study coordinator at the Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Jessica M. Perkins
- PhD, MPH, is a postdoctoral research fellow in the Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, Boston, MA, USA
| | | | - Sheri D. Weiser
- MD, MPH, is Associate Professor of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - David R. Bangsberg
- MD, MPH, is Founding Dean, Oregon Health Sciences University-Portland State University School of Public Health, Portland, OR, USA
| | - Alexander C. Tsai
- MD, is Assistant Professor of Psychiatry at Harvard Medical School, Boston, MA, USA
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Zhang C, Li X, Liu Y, Qiao S, Zhou Y, Shen Z, Chen Y. Substance Use and Psychosocial Status among People Living with HIV/AIDS Who Encountered HIV Stigma in China: Stratified Analyses by Socio-Economic Status. PLoS One 2016; 11:e0165624. [PMID: 27824948 PMCID: PMC5100887 DOI: 10.1371/journal.pone.0165624] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 10/15/2016] [Indexed: 12/22/2022] Open
Abstract
This study examined whether the impact of HIV stigma on psychosocial status and substance use among people living with HIV/AIDS (PLWHA) differed by their socio-economic status (SES) in a Chinese setting. A total of 2,987 PLWHA were recruited from 12 sites with the highest number of cumulative HIV incidence in Guangxi, China. Participants were asked to provide information regarding their psychosocial status (e.g., depression, anxiety), history of substance use (e.g., tobacco, alcohol and drug) and SES (e.g., education, monthly income, residence type, and job category). By employing stratified multivariate regression analyses, we assessed stratum-specific impacts of HIV stigma on PLWHA’s psychosocial status and behaviors of substance use based upon participants’ SES. The impact of HIV stigma differed significantly on psychosocial status across SES gradients. Psychosocial status among people with higher education was more sensitive to HIV stigma compared with PLWHA who were less educated. The odds of substance use behaviors were higher among people with better monthly income than their low-income peers. Our study is the first paper to document the paucity of SES stratified analyses between HIV stigma and psychosocial status and substance use among PLWHA in China. We call for tailored intervention programs to target PLWHA with different backgrounds and characteristics in order to help them to better manage their seropositivity.
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Affiliation(s)
- Chen Zhang
- Divison of Epidemiology, Vanderbilt University, Nashville, Tennessee, United States of America
- * E-mail:
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Yu Liu
- Divison of Epidemiology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Shan Qiao
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States of America
| | - Yuejiao Zhou
- Department of HIV/STD Prevention, Guangxi CDC, Nanning, Guangxi, China
| | - Zhiyong Shen
- Department of HIV/STD Prevention, Guangxi CDC, Nanning, Guangxi, China
| | - Yi Chen
- Department of HIV/STD Prevention, Guangxi CDC, Nanning, Guangxi, China
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Shimizu M, Yi S, Tuot S, Suong S, Sron S, Shibanuma A, Jimba M. The impact of a livelihood program on depressive symptoms among people living with HIV in Cambodia. Glob Health Action 2016; 9:31999. [PMID: 27511811 PMCID: PMC4980519 DOI: 10.3402/gha.v9.31999] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/04/2016] [Accepted: 07/05/2016] [Indexed: 12/29/2022] Open
Abstract
Background Psychological and social problems are major concerns in this era of successful antiretroviral therapy. Although livelihood programs have been implemented extensively to improve the daily living conditions of people living with HIV in Cambodia, no studies have yet investigated the impacts of these programs on the mental health of this vulnerable population. Therefore, we examined the impact of a livelihood program on depressive symptoms and associated factors among people living with HIV in Cambodia. Design A quasi-experimental, nonequivalent comparison group study was conducted in six provinces of Cambodia in 2014. Data were collected from an intervention group comprising 357 people living with HIV who had participated in the livelihood program and a comparison group comprising 328 people living with HIV who had not participated in this program. Multiple logistic regression analysis was carried out to examine the association between livelihood-program participation and depressive symptoms as measured by the depressive symptoms subscale of the 25-item Cambodian version of the Hopkins Symptom Checklist. A propensity score matching was used to examine the effect of the livelihood program on depressive symptoms while controlling for selection bias. Results Overall, 56.0% and 62.7% of the participants in the intervention and comparison groups, respectively, met the Hopkins Symptom Checklist threshold for depressive symptoms. The multiple logistic regression analysis showed that the participants in the intervention group had significantly lower odds of having depressive symptoms (adjusted odds ratio 0.68, 95% confidence interval 0.52–0.88). The analysis from propensity score matching indicated that the livelihood program helped mitigate depressive symptoms among the participants in the intervention group (T=−1.99). Conclusions The livelihood program appeared to help mitigate the burden of depressive symptoms among people living with HIV in Cambodia. Thus, this program should be scaled up and modified to better improve participants’ mental health.
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Affiliation(s)
- Mayumi Shimizu
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Siyan Yi
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Sovannary Tuot
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | - Samedy Suong
- KHANA Center for Population Health Research, Phnom Penh, Cambodia
| | | | - Akira Shibanuma
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan;
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