"You are always hiding. It's the worst way to live." Exploring Stigma in African Immigrants Living With HIV in a Large Northwest U.S. Metropolitan Area

The Effect of Stigma and Social Networks on Role Expectations among African Immigrants Living with HIV

This paper examines how African immigrants living with HIV negotiate and reconstruct their productive (i.e., educational and career opportunities), sexual, and reproductive identities. We used data from a mixed-methods study to explore how stigma and social networks in which participants were embedded shaped how they understood and negotiated their role expectations and responsibilities. Participants revealed how HIV not only changed their identities and limited their sex life, partner choices, and fundamental decisions about fertility and reproduction, but also presented them with the opportunity to reinvent/reshape their lives. Our analysis revealed that the cultural discourses about illness and HIV in participant's countries of origin, the acculturative and migratory stressors, and the competing influences and expectations from family and friends in their home and host countries shape their illness experience, and how they adjust to life with HIV. This paper builds on sociological understanding of illness experience as a social construct that shapes the ill person's identity, role, and function in society. Specifically, the paper contributes to discourses on how (i) participants' social location and identity (as transnational migrants adjusting to acculturative stressors associated with resettlement into a new country), (ii) cultural discourses about illness and HIV in their countries of origin, and (iii) embeddedness in transnational social networks influence health outcomes, including lived experiences with chronic illnesses and stigmatized conditions such as HIV.

Impact of HIV/AIDS on African-born Women Living in the United States: a Systematic Review

BACKGROUND

There is paucity of surveillance data about African-born women (ABW) living with HIV/AIDS in the USA. Out of the 50 US states, only Washington state and Minnesota report HIV surveillance data about African-born people, and Minnesota is the only state that reports data about ABW, specifically. In Minnesota, ABW have the largest prevalence rate of HIV/AIDS among all women. In Washington state, foreign-born Black people have the highest incidence of HIV behind white people and foreign-born Hispanic people. This study aims to better understand the impact HIV/AIDS on ABW.

METHODS

This systematic review is based on articles available on three databases (PubMed, Embase, and Cochrane Library). Databases were searched for articles that included quantitative and/or qualitative findings about the impact of HIV/AIDS on ABW in the USA.

RESULTS

Several themes were identified including disproportionate impact of HIV/AIDS on ABW, barriers to care, low sexual health knowledge, HIV-related stigma, and limited HIV testing. Based on 2013 data, the incidence of HIV among ABW was 12 times higher than the incidence among women in the general US population. In 2008-2014, ABW had the smallest decline in HIV diagnosis rate when compared to US-born men and women, African-born men, and Caribbean-born men and women. Barriers that ABW face when trying to access care include, language barriers, fear of deportation and difficulty navigating the US healthcare system.

CONCLUSION

ABW living in the USA are uniquely impacted by HIV/AIDS. Lasting negative health consequences can be mitigated by improving HIV surveillance and investing in further studies about this population.

Exploring the disability experiences of South Asian Women living with HIV in Southern Ontario, Canada

PURPOSE

Given the steady rise in HIV incidence among South Asian women in Canada their health-related challenges and disability are not well understood. Our aim was to understand the "lived experiences" of disability among South Asian women living with HIV in Southern Ontario, Canada.

METHODS

We conducted a qualitative study using an interpretive phenomenological approach. We recruited immigrant South Asian women living with HIV in Ontario and conducted one-on-one semi structured interviews. Following the first interview, participants were invited to participate in a second interview. Interviews were audio recorded and transcribed verbatim.

RESULTS

Eight participants completed the first interview; six completed a second interview (14 interviews total). The mean age of participants was 47.1 years (standard deviation (sd) = 5.8) and mean length of time since HIV diagnosis was 15.1 years (sd = 6.7). We identified two overarching themes, "experiencing disability" and "experiencing discrimination". Apart from the physical and mental health impairments, the complex intersection of illness, gender, ethnicity, HIV-stigma and discrimination influenced disability experiences.

CONCLUSION

Understanding the disability experiences of marginalized women living with HIV through a phenomenological lens can help to facilitate the development of culturally safe treatment approaches and health care policies to lessen disability and improve their quality of life.Implications for rehabilitationDeveloping culturally safe treatment approaches may help to improve rehabilitation service provision for ethnically and culturally diverse populations.Rehabilitation professionals need to adopt a trauma-informed care when treating people living with HIV.Rehabilitation professionals should consider cultural safety by considering the role of religion, dependency, and gendered-power relations while treating South Asian women living with HIV.

How food support improves mental health among people living with HIV: A qualitative study

BACKGROUND

Food insecurity is associated with poor mental health among people living with HIV (PLHIV). This qualitative study explored the mental health experiences of PLHIV participating in a medically appropriate food support program.

METHODS

Semi-structured interviews were conducted post-intervention (n = 34). Interview topics included changes, or lack thereof, in mental health and reasons for changes. Interviews were audio-recorded, transcribed, and double-coded. Salient themes were identified using an inductive-deductive method.

RESULTS

Positive changes in mental health self-reported by PLHIV included improved mood and reduced stress, worry, and anxiety. Participants attributed these changes to: 1) increased access to sufficient and nutritious foods, 2) increased social support, 3) reduced financial hardship, 4) increased sense of control and self-esteem, and 5) reduced functional barriers to eating.

CONCLUSIONS

Medically appropriate food support may improve mental health for some PLHIV. Further work is needed to understand and prevent possible adverse consequences on mental health after programs end.

HIV attitudes and beliefs in U.S.-based African refugee women

ABSTRACTObjective: The Buffalo, New York region is one of the leading refugee resettlement areas in the country, settling 94% of African refugees in 2014. However, little is known about their health beliefs, particularly regarding sexual health and HIV. This study's purpose was to describe HIV attitudes and beliefs in a sample of African refugee women, a population that is increasingly present in the country, yet seldom represented in the literature.Design: A convenience sample of 101 African refugee women were recruited via snowball technique in Buffalo, New York. Data were collected from July 2017-July 2018, via paper-pen survey, and were analyzed using descriptive statistics.Results: Participants had low levels of education, but high HIV screening rates. Inconsistencies between knowledge of HIV acquisition and behaviors relating to HIV positive individuals may indicate HIV stigma among the population.Conclusion: Novel strategies geared towards educational levels and societal norms to educate African refugee women about HIV are urgently needed.

Transition From Pediatric and Adolescent HIV Care to Adult HIV Care and the Patient-Provider Relationship: A Qualitative Metasynthesis

ABSTRACT

Approximately 5 million adolescents (ages 15-24 years) living with HIV will transition to adult care in the next decade. Only half are engaged in care 12 months post-transition. This qualitative metasynthesis aimed to answer: What effect did the patient-provider relationship (PPR) have on adolescent living with HIV transition? What strategies were suggested to develop trusting relationships to promote engagement and retention in care? Primary qualitative studies from PubMed, CINAHL, and EBSCO (January 2008 to December 2019) were identified. Data were analyzed using team-based thematic synthesis techniques and international standards. Fourteen articles with 478 participants from eight countries were included. Four themes emerged: the familial nature of the PPR, stigma as a bond and barrier, the provider knowing the patient and getting to know new providers, and recommendations supporting transition. The PPR is integral. Collaborative strategies used to build new relationships will support autonomy, decrease stigma, and facilitate trust.

Harambee! 2.0: The Impact of HIV-Related and Intersectional Stigmas on HIV Testing Behaviors Among African Immigrant Communities in Seattle, Washington

African immigrants are disproportionately affected by HIV compared to U.S.-born individuals, and early HIV testing is the key challenge in ending the HIV epidemic in these communities. HIV-related stigma appears to be the most significant barrier to testing for HIV among African communities in King County, WA. In this formative study, we conducted thirty key informant interviews and five focus group discussions (n = total 72 participants) with Ethiopian, Somali, and Eritrean people living with HIV, health professionals, religious and other community leaders, and lay community members in King County to better understand HIV-related and intersectional stigmas' impact on HIV testing behaviors. We used inductive coding and thematic analysis. Participants from all communities reported similar themes for HIV-related and intersectional stigmas' influences on HIV testing behaviors. Misconceptions or poor messaging, e.g., regarding treatability of HIV, as well as normative or religious/moral beliefs around pre/extramarital sex contributed to HIV-related stigma. Intersecting identities such as immigrant status, race/ethnicity, and having a non-English language preference, all intermingle to further influence access to the U.S. healthcare system, including for HIV testing. These findings can be used to inform future research on community-led approaches to addressing early HIV testing amongst African immigrant communities.

A Review of Cultural Influences on Risk for HIV and Culturally-Responsive Risk Mitigation Strategies Among African Immigrants in the US

There is a paucity of research on HIV risk factors and risk reduction among African immigrants living in the US. This is despite the fact that the literature on HIV prevention and treatment continues to grow. We conducted a focused review to identify cultural factors contributing to the high incidence of HIV among African immigrants and best practices to increase engagement in HIV prevention services in this population. We conducted a search for empirical research published between 2009 and 2019, yielding 17 relevant studies with 16 unique samples. Inadequate knowledge about HIV transmission, low HIV risk perception, and stigma may be barriers to engaging in HIV prevention. Targeted interventions included bundled HIV testing, flexible scheduling, and involvement of community leaders in intervention planning and implementation. Implications for practice and directions for future research among this population are discussed.

Undocumented African Immigrants' Experiences of HIV Testing and Linkage to Care

In the United States, undocumented African immigrants living with HIV enter care late, potentially leading to adverse individual and population health outcomes, yet little is known about the specific experiences of HIV diagnosis and linkage to care among this population. We conducted individual, semi-structured interviews with adults who were undocumented African immigrants living with HIV in New York City. Interviews explored perspectives regarding individual, social, institutional, and societal barriers and facilitators of HIV testing and linkage to care. Of 14 participants from 9 different African countries, 9 were women and the median age was 44 years (interquartile range: 42-50). Participants described fear of discovery by immigration authorities as a substantial barrier to HIV testing and linking to initial medical appointments. Actual and perceived structural barriers to both testing and care linkage included difficulty obtaining health insurance and a belief that undocumented immigrants are ineligible for any health services. Participants also expressed reluctance to be tested because of HIV-related stigma within the immigrant communities that they heavily relied on. After diagnosis, however, participants overwhelmingly described a positive role of health and social service providers in facilitating linkage to HIV care. Concerns about immigration status and HIV-related stigma are significant barriers to HIV testing and linkage to care among undocumented African immigrants. Multilevel efforts to reduce stigma and increase awareness of available services could enhance rates of HIV testing and care linkage in this population.

Harambee!: A pilot mixed methods study of integrated residential HIV testing among African-born individuals in the Seattle area

Background

African-born individuals in the U.S. are disproportionately affected by HIV yet have low HIV testing rates. We conducted a mixed methods study to assess the uptake and feasibility of a novel strategy for integrating HIV testing into residential health fairs among African-born individuals in Seattle, WA.

Methods

From April to May 2018, we held six health fairs at three apartment complexes with high numbers of African-born residents. Fairs included free point-of-care screening for glucose, cholesterol, body mass index, blood pressure, and HIV, as well as social services and health education. The health fairs were hosted in apartment complex common areas with HIV testing conducted in private rooms. Health fair participants completed a series of questionnaires to evaluate demographics, access to health services, and HIV testing history. We conducted 18 key informant interviews (KIIs) with health fair participants and community leaders to identify barriers to HIV testing among African-born individuals.

Results

Of the 111 adults who accessed at least one service at a health fair, 92 completed questionnaires. Fifty-five (61%) were female, 48 (52%) were born in Africa, and 55 (63%) had health insurance. Half of African-born participants accepted HIV testing; all tested negative. The most common reasons for declining testing were lack of perceived risk for HIV and knowledge of HIV status. We identified a high prevalence of non-communicable diseases (NCDs) among health fair participants; among those tested, 77% (55/71) were overweight/obese, 39% (31/79) had blood pressure > 140/90 mmHg, and 30% (22/73) had total cholesterol > 200 mg/dL. KIIs identified community stigma and misinformation as major barriers to HIV testing among African-born individuals.

Conclusions

Residential health fairs are a feasible method to increase HIV testing among African-born individuals in Seattle. The high prevalence of NCDs highlights the importance of integrating general preventive services within HIV testing programs in this population.

The Management of Newly Diagnosed HIV in a Sudanese Refugee in Canada: Commentary and Review of Literature

BACKGROUND

Human Immunodeficiency Virus (HIV) prevalence rates in refugee camps are inconclusive in current literature, with some studies highlighting the increased risk of transmission due to poor living conditions and lower levels of education. With the increasing number of refugees from HIV endemic countries, it is important to assess the programs established to support patients upon arrival. Refugees have been reported to have a lower health literacy and face disease-related stigmatization, which must be overcome for the lifelong treatment of HIV.

CASE PRESENTATION

31-year-old female arrived in Canada as a refugee from Sudan with her 5 children in July of 2017. She was diagnosed with HIV and severe dental carries during her initial medical evaluation and referred to our centre. A lack of social support has resulted in severe psychological stress. The first being stigmatization which has led to her not disclosing the diagnosis to anyone outside her medical care team. Her level of knowledge about HIV is consistent with literature reporting that despite HIV prevention programs in refugee camps, compliance with risk reduction behaviors, especially in females, is low. Lastly, her major concern relates to the cost of living and supporting her children.

CONCLUSION

Assessment of current HIV programs is necessary to recognize and resolve gaps in the system. Focusing on programs which increase both risk reduction behaviors in refugee camps and integration of refugees in a new healthcare system can facilitate an easier transition for patients and aid in the quest for global 90-90-90 targets for HIV.