Assessing the Impact of Food Assistance on Stigma Among People Living with HIV in Uganda Using the HIV/AIDS Stigma Instrument-PLWA (HASI-P)

Changes in HIV Internalized and Experienced Stigmas and Social Support After an Urban Gardens and Peer Nutritional Counseling Intervention Among People With HIV and Food Insecurity in the Dominican Republic

BACKGROUND

Food insecurity and HIV-related stigma negatively affect HIV outcomes. Few studies have examined how food security interventions affect HIV-related stigma and social support.

SETTING

Two HIV clinics in the Dominican Republic.

METHODS

A pilot cluster randomized controlled trial of an urban gardens and peer nutritional counseling intervention was conducted to examine outcomes of HIV-related stigmas and social support. Adult patients (≥18 years of age) with moderate or severe household food insecurity and evidence of suboptimal ART adherence and/or a detectable viral load were enrolled; standard measures of internalized and experienced stigmas and social support were collected at baseline and at 6 and 12 months. Intervention clinic participants received training and materials from agronomists for a home garden, 3-4 sessions of nutritional counseling from the clinic's peer counselor, and a garden produce cooking workshop facilitated by professional nutritionists.

RESULTS

Of 109 study participants (46 intervention and 63 control), 103 (94%) completed 12-month follow-up. Difference-in-differences multivariate longitudinal linear regressions adjusting for sociodemographic factors found that intervention participants had reduced internalized stigma by 3.04 points (scale 0-32) at 12 months (P = 0.002); reduced probability of experiencing HIV-related stigma or discrimination in the past 6 months (20 percentage points at 6 months, P = 0.05 and 25 percentage points at 12 months, P = 0.02); and modestly improved social support at 12 months (1.85 points on 30-pt scale, P = 0.093).

CONCLUSION

A fully powered, larger trial is needed to establish the efficacy of the intervention and assess pathways by which the intervention may improve HIV stigma and social support.

Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination

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.

Differences in Reasons for Late Presentation to HIV Care in Uganda Among Men and Women

Late presentation to HIV care, i.e., presenting with < 200 CD4 cells/mL, is associated with higher mortality and worse outcomes. Despite that, a quarter of people living with HIV in Uganda still present late to care. We surveyed Ugandans living with HIV who enrolled in clinic ≤ 90 days prior. We compared groups who presented 'late' with CD4 < 200 and 'early' with CD4 > 350, stratifying by sex. We found men who presented late had higher externalized stigma than early presenters. Thirty-six percent of the entire cohort were depressed. Social support was stronger in late presenters versus early, although weak overall. Social support was inversely correlated with depression, with social support dropping as depression increased. Interventions to improve clinic privacy, reduce stigma, improve social support, and help women disclose their HIV status to male partners are needed to reduce late presentation to HIV care.

HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties

BACKGROUND

The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS.

OBJECTIVE

The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation.

RESULTS

A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation).

CONCLUSIONS

This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.

A Multilevel Integrated Intervention to Reduce the Impact of HIV Stigma on HIV Treatment Outcomes Among Adolescents Living With HIV in Uganda: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda.

OBJECTIVE

The proposed intervention-Multilevel Suubi (MSuubi)-has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants' experiences with HIV stigma, HIV treatment adherence, and intervention and educators' attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training.

METHODS

MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months.

RESULTS

This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025.

CONCLUSIONS

MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40101.

Measurement characteristics and correlates of HIV-related stigma among adults living with HIV: a cross-sectional study from coastal Kenya

OBJECTIVE

We studied the psychometric properties of the 12-item short version of the Berger HIV stigma scale and assessed the correlates of HIV-related stigma among adults living with HIV on the Kenyan coast.

DESIGN

Cross-sectional study.

SETTING

Comprehensive Care and Research Centre in the Kilifi County Hospital.

PARTICIPANTS

Adults living with HIV on combination antiretroviral therapy were recruited and interviewed between February and April 2018 (n=450).

MAIN OUTCOME MEASURES

HIV-related stigma.

RESULTS

450 participants with a median age of 43 years (IQR=36-50) took part in the study. Of these, 356 (79.1%) were female. Scale reliability and validity were high (alpha=0.80, test-retest reliability intraclass correlation coefficient=0.92). Using confirmatory factor analysis, we observed that the 12-item short version of the HIV stigma scale had a good fit for its hypothesised model (Comparative Fit Index=0.966, Tucker Lewis Index=0.955, root mean square error of approximation=0.044). Multigroup confirmatory factor analysis indicated measurement invariance across gender and age groups as ΔCFI was ≤0.01. Multivariate linear regression established that being female (β=2.001, 95% CI: 0.21 to 3.80, p=0.029), HIV status non-disclosure (β=4.237, 95% CI: 1.27 to 7.20, p=0.005) and co-occurrence of depressive and anxiety symptoms (β=6.670, 95% CI: 3.40 to 9.94, p<0.001) were significant predictors of perceived HIV-related stigma and that these variables accounted for 10.2% of the explained variability in HIV-related stigma among adults living with HIV from Kilifi.

CONCLUSIONS

Our results indicate that the 12-item short version of the HIV stigma scale is a valid and reliable measure of HIV stigma in Kenya. Furthermore, our study indicates that interventions aimed at reducing stigma need to take into account gender to address the specific needs of women, people who have not disclosed their HIV status, and those exhibiting symptoms of depression and anxiety, thereby improving their quality of life.

Mechanisms and perceived mental health changes after a livelihood intervention for HIV-positive Kenyans: Longitudinal, qualitative findings

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.

'Management of a spoiled identity': systematic review of interventions to address self-stigma among people living with and affected by HIV

Background

Self-stigma, also known as internalised stigma, is a global public health threat because it keeps people from accessing HIV and other health services. By hampering HIV testing, treatment and prevention, self-stigma can compromise the sustainability of health interventions and have serious epidemiological consequences. This review synthesised existing evidence of interventions aiming to reduce self-stigma experienced by people living with HIV and key populations affected by HIV in low-income and middle-income countries.

Methods

Studies were identified through bibliographic databases, grey literature sites, study registries, back referencing and contacts with researchers, and synthesised following Cochrane guidelines.

Results

Of 5880 potentially relevant titles, 20 studies were included in the review. Represented in these studies were 9536 people (65% women) from Ethiopia, India, Kenya, Lesotho, Malawi, Nepal, South Africa, Swaziland, Tanzania, Thailand, Uganda and Vietnam. Seventeen of the studies recruited people living with HIV (of which five focused specifically on pregnant women). The remaining three studies focused on young men who have sex with men, female sex workers and men who inject drugs. Studies were clustered into four categories based on the socioecological level of risk or resilience that they targeted: (1) individual level only, (2) individual and relational levels, (3) individual and structural levels and (4) structural level only. Thirteen studies targeting structural risks (with or without individual components) consistently produced significant reductions in self-stigma. The remaining seven studies that did not include a component to address structural risks produced mixed effects.

Conclusion

Structural interventions such as scale-up of antiretroviral treatment, prevention of medication stockouts, social empowerment and economic strengthening may help substantially reduce self-stigma among individuals. More research is urgently needed to understand how to reduce self-stigma among young people and key populations, as well as how to tackle intersectional self-stigma.

It's not "all in your head": critical knowledge gaps on internalized HIV stigma and a call for integrating social and structural conceptualizations

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.

Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator

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.

HIV, violence, blame and shame: pathways of risk to internalized HIV stigma among South African adolescents living with HIV

INTRODUCTION

Internalized HIV stigma is a key risk factor for negative outcomes amongst adolescents living with HIV (ALHIV), including non-adherence to anti-retroviral treatment, loss-to-follow-up and morbidity. This study tested a theoretical model of multi-level risk pathways to internalized HIV stigma among South African ALHIV.

METHODS

From 2013 to 2015, a survey using total population sampling of ALHIV who had ever initiated anti-retroviral treatment (ART) in 53 public health facilities in the Eastern Cape, South Africa was conducted. Community-tracing ensured inclusion of ALHIV who were defaulting from ART or lost to follow-up. 90.1% of eligible ALHIV were interviewed (n = 1060, 55% female, mean age = 13.8, 21% living in rural locations). HIV stigma mechanisms (internalized, enacted, and anticipated), HIV-related disability, violence victimization (physical, emotional, sexual abuse, bullying victimization) were assessed using well-validated self-report measures. Structural equation modelling was used to test a theoretically informed model of risk pathways from HIV-related disability to internalized HIV stigma. The model controlled for age, gender and urban/rural address.

RESULTS

Prevalence of internalized HIV stigma was 26.5%. As hypothesized, significant associations between internalized stigma and anticipated stigma, as well as depression were obtained. Unexpectedly, HIV-related disability, victimization, and enacted stigma were not directly associated with internalized stigma. Instead significant pathways were identified via anticipated HIV stigma and depression. The model fitted the data well (RMSEA = .023; CFI = .94; TLI = .95; WRMR = 1.070).

CONCLUSIONS

These findings highlight the complicated nature of internalized HIV stigma. Whilst it is seemingly a psychological process, indirect pathways suggest multi-level mechanisms leading to internalized HIV stigma. Findings suggest that protection from violence within homes, communities and schools may interrupt risk pathways from HIV-related health problems to psychological distress and internalized HIV stigma. This highlights the potential for interventions that do not explicitly target adolescents living with HIV but are sensitive to their needs.