Social consequences of HIV-positive women's participation in prevention of mother-to-child transmission programmes

Increasing Prevention of Mother to Child Transmission (PMTCT) Uptake through Facility-Based Health Promotion: Intervention Development

In Sudan, the HIV testing rates during pregnancy remain low. Limitations in scaling and uptake of PMTCT services are linked to several factors within the healthcare system, including the motivation of healthcare providers. This article describes how a health facility-based health promotion intervention plan was developed, implemented, and evaluated to increase the uptake of PMTCT services using the Intervention Mapping approach. Individual-level and environmental determinants were previously identified and included in the intervention plan. Some factors that impacted the intention of women to test for HIV during pregnancy include level of knowledge on MTCT, who offers the HIV test, the fear and tension experienced when thinking about HIV/AIDS, the non-confidentiality of the HIV test results, and self-efficacy. This provides insights into how to develop, implement, and evaluate a facility-based health promotion intervention. The pre-assessment was critical in shaping the intervention and making it relevant and evidence based. The Intervention Mapping approach that was applied facilitated the systematic design of the intervention and supported guiding the implementation.

A total facility approach to reducing HIV stigma in health facilities: implementation process and lessons learned

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.

"I was afraid my baby would be upset with me" - women living with HIV's accounts going through non-breastfeeding in São Paulo, Brazil

In Brazil prevention of mother to child HIV transmission guidelines recommend formula feeding. This qualitative study, carried out in a public clinic (CEADIPE/UNIFESP), aimed at exploring experiences of breastfeeding avoidance of women living with HIV living in São Paulo. Individual interviews were carried out with the support of a semi-structured questionnaire. Data was analyzed in a thematic approach with the support of AtlasTi^®. During the months of January-February 2010, 25 women were interviewed, including women with (n = 12) and without previous breastfeeding experience (n = 13). Major themes identified were: Non-breastfeeding as a trigger for stigmatization, Non-breastfeeding, guilt and coping, Attitudes around non-breastfeeding for women with and without previous breastfeeding experience, and Women's support through non-breastfeeding. In conclusion women interviewed faced challenges related to HIV diagnosis, which got entangled with difficulties with breastfeeding avoidance. Different patterns of reaction and coping could be identified, regardless of mothers' previous breastfeeding experiences. Health systems were key in providing women living with HIV with tailored services and the necessary support.

Suubi+Adherence study protocol: A family economic empowerment intervention addressing HIV treatment adherence for perinatally infected adolescents

Background

Globally, 1.8 million children<15 years are living with HIV. Sub-Saharan Africa (SSA), as a region, is heavily burdened by HIV, with 90% of new infections among children happening there. Within SSA, Uganda has an HIV prevalence of 7.2% among 15-49-year-olds, with high prevalence in Masaka region (12%). Uganda also reports unprecedented numbers of perinatally HIV-infected children, with close to 150,000 children (ages 0–14) living with HIV (CLHA). However adherence to antiretroviral therapy (ART) among children and youth is poor, and has been attributed to economic insecurity, including lack of finances for transportation to clinic appointments, inadequate meals to support medication consumption, and resource prioritization towards school expenses. Yet, few programs aimed at addressing ART adherence have applied combination interventions to address economic stability and ART Adherence within the traditional framework of health education and HIV care. This paper describes a study protocol for a 5-year, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) funded, cluster randomized-controlled trial to evaluate a combination intervention, titled Suubi + Adherence, aimed at improving ART adherence among HIV perinatally infected adolescents (ages 10–16 at study enrollment) in Uganda.

Methods

Suubi + Adherence was evaluated via a two-arm cluster randomized-controlled trial design in 39 health clinics, with a total enrollment of 702 HIV + adolescents (ages 10–16 at enrollment). The study addresses two primary outcomes: 1) adherence to HIV treatment regimen and 2) HIV knowledge and attitudes. Secondary outcomes include family functioning, sexual risk-taking behavior, and financial savings behavior. For potential scale-up, cost effectiveness analysis was employed to compare the relative costs and outcomes associated with each study arm: family economic strengthening comprising matched savings accounts, financial management training and small business development, all intended for family economic security versus bolstered usual care (SOC) comprising enhanced adherence sessions to ensure more standardized and sufficient adherence counseling.

Discussion

This study aims to advance knowledge and inform the development of the next generation of programs aimed at increasing adherence to HIV treatment for HIV + adolescents in low-resource regions such as SSA. To our knowledge, the proposed study is the first to integrate and test family economic empowerment and stability-focused interventions for HIV + adolescents in Uganda (and much of SSA)—so families would have the necessary finances to manage HIV/AIDS as a chronic illness. The study would provide crucial evidence about the effects of an economic empowerment program on short and long-term impact, which is essential if such interventions are to be taken to scale.

Trial registration

This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

'If nurses were in our shoes would they breastfeed their own babies?' A qualitative inquiry on challenges faced by breastfeeding mothers on the PMTCT programme in a rural community in Zimbabwe

BACKGROUND

The Prevention of Mother to Child Transmission (PMTCT) of HIV programme in Zimbabwe has had remarkable success despite the country's economic challenges. The aim of this study was to explore the challenges faced by breastfeeding mothers on the PMTCT programme.

METHOD

Narratives from 15 women (age range 19-35 years) were collected at two rural health facilities in Zimbabwe through in-depth interviews over a period of 6 months. Thematic analysis was used to describe breastfeeding mothers' experiences and challenges of being on the PMTCT programme.

RESULTS

The findings suggest that breastfeeding women on the PMTCT programme face challenges that include internal, external and institutional stigma and discrimination. Women reported a sense of powerlessness in decision making on following through with the PMTCT programme and were ambivalent regarding disclosure of their HIV status to their partners and significant others.

CONCLUSION

HIV and AIDS programmes should pay attention to women's readiness for interventions. There is need to understand women's life experiences to ensure informed and targeted programming for PMTCT.

Why is mother to child transmission (MTCT) of HIV a continual threat to new-borns in sub-Saharan Africa (SSA)

Sub-Saharan Africa (SSA) accounts for more than two thirds of the world's HIV infection. Despite scaled-up prevention of mother-to-child transmission of HIV (PMTCT) programmes, mother to child transmission of HIV (MTCT) continues to escalate. We describe the challenges faced by PMTCT in MTCT in SSA. The study reviewed articles and reports published online. The most common barriers and challenges were non-disclosure of HIV status, late initiation of ARVs treatment/adherence, STIs screening, long clinics waiting time, non-involvement of men in ANC/PMTCT, infant feeding methods and sensitization of community members on ANC/PMTCT programmes. The study highlights the need to expand PMTCT coverage and the implementation of the 90-90-90 programme toward MTCT elimination in SSA. That is " ≥90% of pregnant and breast-feeding mothers must know their HIV status; ≥90% of those that are positive are enrolled on ARVs treatment and care; ≥90% of those on ARVs treatment and care are virally suppressed.

Intervening factors in the feeding of infants vertically-exposed to HIV: an integrative review

Objective

To evaluate the available scientific literature on factors that may intervene in the adequate feeding of infants vertically-exposed to HIV.

Methods

This was an integrative review of the literature, performed on the LILACS, PubMed and Scopus databases in February 2017. The search was guided by the question "What are the factors involved in feeding infants vertically-exposed to HIV." Selected studies met the inclusion criteria of being research articles published in English, Portuguese, or Spanish. Articles excluded were those on exclusive breastfeeding. There was no need to perform a temporal cut off of the studies.

Results

In all, the 32 primary studies selected showed that intervening factors were of three types: individual, such as maternal feelings and desires, beliefs, and practical difficulties; social, such as socioeconomic conditions, social support, and stigma; and political, such as health services structure and organization, supplies, health care guidance, and the knowledge and attitudes of health care professionals.

Conclusions

The factors that interfere with feeding infants vertically-exposed to HIV may be independent or associated with each other. To reduce the risk of inadequate nutrition and its associated diseases, actions must be taken to identify and minimize these factors, guaranteeing a better quality of life and reduction of infant morbidity and mortality.

Lessons learned from the PMTCT program in Swaziland: challenges with accepting lifelong ART for pregnant and lactating women - a qualitative study

Background

Swaziland has one of the highest HIV prevalence rates in sub-Saharan Africa, 26 % of the adult population is infected with HIV. The prevalence is highest among pregnant women, at 41.1 %. According to Swaziland’s prevention of mother-to-child transmission (PMTCT) guidelines, approximately 50 % of pregnant women are eligible for antiretroviral therapy (ART) by CD4 criteria (<350 cells/ml). Studies have shown that most mother-to-child transmission and postnatal deaths occur among women who are eligible for ART. Therefore, ensuring that ART eligible women are initiated on ART is critical for PMTCT and for mother and baby survival. This study provides insight into the challenges of lifelong ART initiation among pregnant women under Option A in Swaziland. We believe that these challenges and lessons learned from initiating women on lifelong ART under Option A are relevant and important to consider during implementation of Option B+.

Methods

HIV-positive, treatment-eligible, postpartum women and nurses were recruited within maternal and child health (MCH) units using convenience and purposive sampling. Participants came from both urban and rural areas. Focus group discussions (FGDs) and structured interviews using a short answer questionnaire were conducted to gain an understanding of the challenges experienced when initiating lifelong ART. Seven FGDs (of 5–11 participants) were conducted, four FGDs with nurses, two FGDs with women who initiated ART, and one FGD with women who did not initiate ART. A total of 83 interviews were conducted; 50 with women who initiated ART and 33 with women who did not initiate. Data collection with the women was conducted in the local language of SiSwati and data collection with the nurses was done in English. FGDs were audio-recorded and simultaneously transcribed and translated into English. Analysis was conducted using thematic analysis. Transcripts were coded by two researchers in the qualitative software program MAXqda v.10. Thematic findings were illustrated using verbatim quotes which were selected on the basis of being representative of a specific theme. The short-answer interview questionnaire included specific questions about the different steps in the woman’s experience initiating ART; therefore the responses for each question were analyzed separately.

Results

Findings from the study highlight women feeling overwhelmed by the lifetime commitment of ART, feeling “healthy” when asked to initiate ART, preference for short-course prophylaxis and fear of side effects (body changes). Also, the preference for nurses to determine on an individual basis the number of counseling appointments a woman needs before initiating ART, more information about HIV and ART needed at the community level, and the need to educate men about HIV and ART.

Conclusion

Women face a myriad of challenges initiating lifelong ART. Understanding women’s concerns will aid in developing effective counseling messages, designing appropriate counseling structures, understanding where additional support is needed in the process of initiating ART, and knowing who to target for community level messages.

Perceptions of Sudanese women of reproductive age toward HIV/AIDS and services for Prevention of Mother-to-Child Transmission of HIV

BACKGROUND

Access to antenatal HIV testing during pregnancy and the level of uptake of services for Prevention of Mother-to-Child Transmission (PMTCT) in Sudan are very low. This study aimed to obtain insights into the perceptions of Sudanese pregnant women toward HIV/AIDS and the use of PMTCT services.

METHODS

Ten focus group discussions (FGDs) with women of reproductive age were conducted at community settings in Khartoum (N = 121). Recruitment eligibility included living near or around a PMTCT site and being in the age range of 18-40 years. Out of 121 women who participated, 72 (61 %) were pregnant. Predefined themes were addressed in the theory-based interview scheme, which was derived from multiple socio-cognitive theories-i.e., the Extended Parallel Process Model, the Reasoned Action Approach and the socio-psychological view on stigma. Emerging themes were incorporated during data analysis.

RESULTS

Few women knew about the Mother to child transmission (MTCT) of HIV. No one indicated that MTCT might occur during labor. Most women believed that HIV/AIDS is a serious and fatal condition for them and also for their children. They believed they were susceptible to HIV/AIDS as a result of cesarean section, contaminated items (blood and sharp items) and husband infidelity. The usefulness and advantages of HIV testing were questioned; for some women it was perceived as an additional burden of anxiety and worry. Doctors were the most influential with regard to acceptance of HIV testing. The speed of the testing process and confidentiality were mentioned by some women as key factors affecting willingness to undergo HIV testing at a health facility during pregnancy.

CONCLUSION

The study reveals that most of the women felt susceptible to HIV infection with perceived high severity; however, this perception has not translated into positive attitudes toward the importance of HIV testing during pregnancy. Because of anticipated stigma, women are not likely to disclose their HIV status. Further research should focus on gaining a more in-depth understanding of the psycho-social determinants and processes underlying the factors identified above. In addition, the adequate implementation of Provider Initiated Testing and Counseling (PITC) should be critically assessed in future research about PMTCT in Sudan.

Boundaries of confidentiality in nursing care for mother and child in HIV programmes

BACKGROUND

Confidentiality lies at the core of medical ethics and is the cornerstone for developing and keeping a trusting relationship between nurses and patients. In the wake of the HIV epidemic, there has been a heightened focus on confidentiality in healthcare contexts. Nurses' follow-up of HIV-positive women and their susceptible HIV-exposed children has proved to be challenging in this regard, but the ethical dilemmas concerning confidentiality that emerge in the process of ensuring HIV-free survival of the third party - the child - have attracted limited attention.

OBJECTIVE

The study explores challenges of confidentiality linked to a third party in nurse-patient relationships in a rural Tanzanian HIV/AIDS context.

STUDY CONTEXT

The study was carried out in rural and semi-urban settings of Tanzania where the population is largely agro-pastoral, the formal educational level is low and poverty is rife. The HIV prevalence of 1.5% is low compared to the national prevalence of 5.1%.

METHODS

Data were collected during 9 months of ethnographic fieldwork and consisted of participant observation in clinical settings and during home visits combined with in-depth interviews. The main categories of informants were nurses employed in prevention of mother-to-child transmission of HIV programmes and HIV-positive women enrolled in these programmes.

ETHICAL CONSIDERATIONS

Based on information about the study aims, all informants consented to participate. Ethical approval was granted by ethics review boards in Tanzania and Norway.

FINDINGS AND DISCUSSION

The material indicates a delicate balance between the nurses' attempt to secure the HIV-free survival of the babies and the mothers' desire to preserve confidentiality. Profound confidentiality-related dilemmas emerged in actual practice, and indications of a lack of thorough consideration of the implication of a patient's restricted disclosure came to light during follow-up of the HIV-positive women and the third party - the child who is at risk of HIV infection through mother's milk. World Health Organization's substantial focus on infant survival (Millennium Development Goal-4) and the strong calls for disclosure among the HIV-positive are reflected on in the discussion.

Economic and social factors are some of the most common barriers preventing women from accessing maternal and newborn child health (MNCH) and prevention of mother-to-child transmission (PMTCT) services: a literature review

Support to health programming has increasingly placed an emphasis on health systems strengthening. Integration of prevention of mother-to-child transmission (PMTCT) and maternal and newborn child health (MNCH) services has been one of the areas where there has been a shift from a siloed to a more integrated approach. The scale-up of anti-retroviral therapy has made services increasingly available while also bringing them closer to those in need. However, addressing supply side issues around the availability and quality of care at the health centre level alone cannot guarantee better results without a more explicit focus on access issues. Access to PMTCT care and treatment services is affected by a number of barriers which influence decisions of women to seek care. This paper reviews published qualitative and quantitative studies that look at demand side barriers to PMTCT services and proposes a categorisation of these barriers. It notes that access to PMTCT services as well as eventual uptake and retention in PMTCT care starts with access to MNCH in general. While poverty often prevents women, regardless of HIV status, from accessing MNCH services, women living with HIV who are in need of PMTCT services face an additional set of PMTCT barriers. This review proposes four categories of barriers to accessing PMTCT: social norms and knowledge, socioeconomic status, physiological status and psychological conditions. Social norms and knowledge and socioeconomic status stand out. Transport is the most frequently mentioned socioeconomic barrier. With regard to social norms and knowledge, non-disclosure, stigma and partner relations are the most commonly cited barriers. Some studies also cite physiological barriers. Barriers related to social norms and knowledge, socioeconomic status and physiology can all be affected by the mental and psychological state of the individual to create a psychological barrier to access. Increased coverage and uptake of PMTCT services can be achieved if policy makers and programme managers better understand the barriers that may prevent their potential target population from taking up and adhering to their services. The categorisation presented in this review provides further insight into the type of barriers that may exist .

Experiences of stigma among women living with HIV attending sexual and reproductive health services in Kenya: a qualitative study

Background

Researchers have widely documented the pervasiveness of HIV stigma and discrimination, and its impact on people living with HIV. Only a few studies, however, have analysed the perceptions of women living with HIV accessing sexual and reproductive health (SRH) services. This study explores the experiences of stigma of HIV-positive clients attending family planning and post-natal services and implications for service use and antiretroviral therapy (ART) adherence. Our aim was to gain a better understanding of the impact of various dimensions of stigma on service use and ART adherence among HIV clients in order to inform the response of integrated SRH services.

Methods

In-depth interviews were conducted with 48 women living with HIV attending SRH services in two districts in Kenya. Data were coded using Nvivo 8 and analysed using a thematic analysis approach.

Results

Findings show that many women living with HIV report high levels of anticipated stigma, resulting in a desire to hide their status from family and friends for fear of being discriminated against. Many women feared desertion following disclosure of their positive status to partners. Consequently some women preferred to hide their status and adhere to HIV treatment in secret. However, the majority of study participants attending postnatal care (PNC) services also revealed that anticipated stigma does not adversely affect their HIV drug uptake and ART adherence, as their drive to live outweighs their fear of stigma. Our findings also seem to suggest a preference for specialist HIV services by some family planning (FP) clients because of better confidentiality and reduced opportunities for unwanted disclosure that could lead to stigma.

Conclusions

The findings highlight that anticipated stigma leading to low disclosure is widespread and sometimes reinforced by health providers’ actions and facility layout (contributing to enacted stigma). However, the motivation to stay healthy and look after the children appears in many cases to override fears of stigma related to ART adherence in our client-based sample.

Stigma against people with HIV/AIDS in rural Ethiopia, 2005 to 2011: signs and predictors of improvement

This study sought to determine trends in and factors associated with stigma against people with HIV/AIDS in Ethiopia. Rural data from the 2005 and 2011 Demographic and Health Surveys were analyzed. HIV testing rates among males increased dramatically from 2005 to 2011 (8-35 %). Among females, testing rates dropped 10 % during the same period. HIV knowledge was associated with stigma, shown by a negative correlation in both data waves, but groups with higher knowledge tended to have lower stigma. Lower levels of knowledge were uniformly associated with higher levels of stigma, but higher levels of knowledge, combined with higher levels of education, were associated with lower levels of stigma in a multiplicative way. Improvements in knowledge can serve as an important intermediate process to behavior change. The found interaction suggests improvements in either education or knowledge can reduce stigma, and when both are improved, stigma reduction will be more dramatic.

Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions

INTRODUCTION

HIV stigma inflicts hardship and suffering on people living with HIV (PLHIV) and interferes with both prevention and treatment efforts. Health professionals are often named by PLHIV as an important source of stigma. This study was designed to examine rates and drivers of stigma and discrimination among doctors, nurses and ward staff in different urban healthcare settings in high HIV prevalence states in India.

METHODS

This cross-sectional study enrolled 305 doctors, 369 nurses and 346 ward staff in both governmental and non-governmental healthcare settings in Mumbai and Bengaluru, India. The approximately one-hour long interviews focused on knowledge related to HIV transmission, personal and professional experiences with PLHIV, instrumental and symbolic stigma, endorsement of coercive policies, and intent to discriminate in professional and personal situations that involve high and low risk of fluid exposure.

RESULTS

High levels of stigma were reported by all groups. This included a willingness to prohibit female PLHIV from having children (55 to 80%), endorsement of mandatory testing for female sex workers (94 to 97%) and surgery patients (90 to 99%), and stating that people who acquired HIV through sex or drugs "got what they deserved" (50 to 83%). In addition, 89% of doctors, 88% of nurses and 73% of ward staff stated that they would discriminate against PLHIV in professional situations that involved high likelihood of fluid exposure, and 57% doctors, 40% nurses and 71% ward staff stated that they would do so in low-risk situations as well. Significant and modifiable drivers of stigma and discrimination included having less frequent contact with PLHIV, and a greater number of transmission misconceptions, blame, instrumental and symbolic stigma. Participants in all three groups reported high rates of endorsement of coercive measures and intent to discriminate against PLHIV. Stigma and discrimination were associated with multiple modifiable drivers, which are consistent with previous research, and which need to be targeted in future interventions.

CONCLUSIONS

Stigma reduction intervention programmes targeting healthcare providers in urban India need to address fear of transmission, improve universal precaution skills, and involve PLHIV at all stages of the intervention to reduce symbolic stigma and ensure that relevant patient interaction skills are taught.

HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence

The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this "PMTCT cascade". Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.

"Sisters, Mothers, Daughters and Aunties": HIV vaccine acceptability among African, Caribbean and other Black women in Toronto

OBJECTIVES

Black women in Canada are at disproportionately high risk for HIV. We assessed HIV vaccine acceptability and correlates of acceptability among Black women from African and Caribbean communities in Toronto.

METHODS

"Sisters, Daughters, Mothers, and Aunties" was a community-based research project. Black women of African and Caribbean descent were recruited using venue-based sampling across diverse community organizations in Toronto. We used a structured questionnaire to collect data on socio-demographic characteristics and acceptability of 8 future HIV vaccines, each defined by a set of 7 dichotomous attributes. Conjoint analysis was used to quantify the relative impact of vaccine attributes on acceptability, with multiple regression to adjust for socio-demographic characteristics associated with overall acceptability.

RESULTS

Mean vaccine acceptability was 58.8 (SD=17.2) on the 100-point scale. Efficacy had the greatest impact on acceptability, followed by side effects, cost, duration of protection, and number of doses. Acceptability of a high (99%) efficacy vaccine (70.1/100) was significantly greater than for a 50% efficacy vaccine (47.6/100). Vaccine acceptability was significantly higher among women of Caribbean versus African descent, ever married versus single women, and women with full-time versus part-time employment.

CONCLUSIONS

Black women in Toronto indicated a modest level of acceptability for future HIV vaccines. Educational interventions that address the benefits of partially efficacious vaccines and clearly explain potential side effects, as well as vaccine cost subsidies may promote HIV vaccine uptake. Differences in acceptability within Black communities suggest that tailored multi-level interventions may mitigate barriers to uptake.

Development and Assessment of Traditional and Innovative Media to Reduce Individual HIV/AIDS-Related Stigma Attitudes and Beliefs in India

Although stigma is considered a major barrier to effective response to the HIV/AIDS epidemic, there is a lack of evidence on effective interventions. This media intervention took place among key HIV-vulnerable communities in Southern India. Two HIV stigma videos were created using techniques from traditional film production and new media digital storytelling. A series of 16 focus group discussions were held in 4 rural and 4 urban sites in South India, with specific groups for sex workers, men who have sex with men, young married women, and others. Focus groups with viewers of the traditional film (8 focus groups, 80 participants) and viewers of the new media production (8 focus groups, 69 participants) revealed the mechanisms through which storyline, characters, and esthetics influence viewers’ attitudes and beliefs about stigma. A comparative pre-/post-survey showed that audiences of both videos significantly improved their stigma scores. We found that a simple illustrated video, produced on a limited budget by amateurs, and a feature film, produced with an ample budget by professionals, elicited similar responses from audiences and similar positive short-term outcomes on stigma.

Economic empowerment and AIDS-related stigma in rural Kenya: a double-edged sword?

Economic empowerment, HIV risk and AIDS-related stigma appear intricately intertwined for women in Kenya. Their interaction must be understood in order to implement effective economic interventions that also decrease HIV risk and stigma. We conducted a qualitative study amongst women in a rural Kamba-speaking community of southeastern Kenya to pursue whether engagement in an economic empowerment initiative (a basket weaving cooperative) influences women's perspectives and experiences with HIV risk and AIDS-related stigma. We conducted seven women's focus groups: participants in the local basket-weaving cooperative comprised four focus groups and non-participants comprised the remaining three groups. The HIV status of the women was not known. Three dominant themes emerged from the focus groups: empowerment, pervasive vulnerability and unanticipated social paradoxes. Contradictions found in these themes suggest that economic empowerment can become a double-edged sword. Economic empowerment enhanced perceived individual, domestic and social community status. However, this enhancement was not protective of domestic violence and perceived HIV risk. Social perceptions may have paradoxically contributed barriers to HIV testing and treatment putting women at greater HIV risk. In conclusion, economic empowerment initiatives for women in developing countries in the context of the HIV epidemic should be coupled with peer mediated support and HIV-risk education.

Correlates of stigma among rural Indian women living with HIV/AIDS

AIDS-related stigma has received increasing attention in the literature; however, little is known about the devastating impact it has on rural women living with AIDS (WLA) in India. This cross-sectional study (N = 68), analyzed from complete baseline data, identified a number of correlates of stigma among rural WLA in South India. Structured instruments were used to capture sociodemographic history, stigma, knowledge of HIV, depressive symptoms along with the recording of CD4 data. A higher level of felt stigma and more AIDS symptoms were related to avoidant coping, while fewer adherence strategies and lower support for antiretroviral therapy (ART) adherence were also associated with avoidant coping. These findings promote the need for support and resources for rural Indian WLA.

Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes

BACKGROUND

Despite efforts to increase the uptake of prevention of mother to child transmission of HIV (PMTCT) services, coverage is still lower than desired in developing countries. A lack of male partner involvement in PMTCT services is a major barrier for women to access these services.

OBJECTIVES

To evaluate the impact of interventions which aim to enhance male involvement to increase women's uptake of PMTCT interventions in developing countries.

SEARCH METHODS

We searched the following databases from the year 2000 to November 2011: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, the WHO Global Health Library, ClinicalTrials.gov, Current Controlled Trials, AEGIS, CROI, IAS, IAC web sites.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised controlled trials, quasi-randomised controlled trials, controlled before and after studies and interrupted time series studies assessing interventions to increase male involvement for improvement of uptake PMTCT services in low- and middle-income countries..

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched, screened, assessed study quality and extracted data. A third reviewer resolved any disagreement.

MAIN RESULTS

Only one study met the inclusion criteria, an RCT conducted in Tanzania between May 2003 and October 2004. Women in the intervention group (n=760) received a letter for their male partners, which invited them to return together to receive Couple Voluntary Counselling and Testing (CVCT) for HIV. Women in the control group (n=761) received individual HIV VCT during their first ANC visit and then usual care. The percentages of women who received HIV VCT and collected their results were 48%, 45% and 39% in the intervention group and 93%, 78% and 71% in the control group (p <0,001). Only 33% of women in the intervention group returned with their male partners and only 47% of them went through the whole CVCT process. The proportion of women who received HIV prophylaxis at delivery was not different between the two arms (27% in the intervention and 22% in the control group). The study had a high risk of bias.  

AUTHORS' CONCLUSIONS

We found only one eligible study that assessed the effectiveness of male involvement in improving women's uptake of PMTCT services, which only focused on one part of the perinatal PMTCT cascade. We urgently need more rigorously designed studies assessing the impact of male engagement interventions on women's uptake of PMTCT services to know if this intervention can contribute to improve uptake of PMTCT services and reduce vertical transmission of HIV in children.   

Blame, symbolic stigma and HIV misconceptions are associated with support for coercive measures in urban India

This study was designed to examine the prevalence of stigma and its underlying factors in two large Indian cities. Cross-sectional interview data were collected from 1,076 non-HIV patients in multiple healthcare settings in Mumbai and Bengaluru, India. The vast majority of participants supported mandatory testing for marginalized groups and coercive family policies for PLHA, stating that they “deserved” their infections and “didn’t care” about infecting others. Most participants did not want to be treated at the same clinic or use the same utensils as PLHA and transmission misconceptions were common. Multiple linear regression showed that blame, transmission misconceptions, symbolic stigma and negative feelings toward PLHA were significantly associated with both stigma and discrimination. The results indicate an urgent need for continued stigma reduction efforts to reduce the suffering of PLHA and barriers to prevention and treatment. Given the high levels of blame and endorsement of coercive policies, it is crucial that such programs are shaped within a human rights framework.

The acceptance and feasibility of replacement feeding at 6 months as an HIV prevention method in Lilongwe, Malawi: results from the BAN study

International guidelines recommend EBF to age 6 months among HIV-infected mothers choosing to breast-feed and cessation thereafter if replacement feeding is acceptable, feasible, affordable, sustainable, and safe. When mothers wean, they are challenged to provide an adequate replacement diet. This study investigates the use and acceptability of a lipid-based nutrient supplement (LNS) as a breast-milk substitute when provided to infants (6-12 mo) of HIV-positive mothers, as part of the Breast-feeding, Antiretroviral, and Nutrition (BAN) Study. A sub-sample of mothers (n = 45) participated in interviews that explored EBF, weaning, and strategies to feed LNS. Mothers reported several weaning strategies, including gradual reduction of breast-feeding, expressing breast-milk into a cup, and separation of mother and child. LNS, a peanut-based micronutrient fortified paste, was highly accepted and incorporated into the traditional diet. Weaning is a feasible HIV prevention method among this population in Malawi when supported by the provision of LNS as a breast-milk substitute.

Factors associated with perceived stigma among people living with HIV/AIDS in post-conflict northern Uganda

HIV-related stigma continues to persist in several African countries including Uganda. This study quantified the burden of stigma and examined factors associated with stigma among 476 people living with HIV (PLHTV) in Gulu, northern Uganda. Data were collected between February and May 2009 using the HIV/AIDS Stigma Instrument-PLWA. Females more than males, respondents aged above 30 years, and those who had been on antiretroviral therapy for a longer time experienced higher levels of stigma. Verbal abuse and negative self-perception were more common forms of stigma. The association between antiretroviral therapy and stigma suggested that organizational aspects of antiretroviral delivery may lead to stigmatization of PLHIV. Interventions such as counseling of PLHIV, education of health workers and the community would lead to reductions in negative self-perception and verbal abuse and in turn improve the quality of life for PLHIV in northern Uganda.

Factors influencing utilization of postpartum CD4 count testing by HIV-positive women not yet eligible for antiretroviral treatment

Delayed antiretroviral initiation is associated with increased mortality, but individuals frequently delay seeking treatment. To increase early antiretroviral therapy (ART) enrollment of HIV-positive women, antenatal clinics are implementing regular, postpartum CD4 count testing. We examined factors influencing women's utilization of extended CD4 count testing. About 53 in-depth interviews were conducted with nurses, patients, social support persons, and government health officials at three antenatal clinics in Lilongwe, Malawi. Counseling and positive interactions with staff emerged as facilitating factors. Women wanted to know their CD4 count, but didn't understand the importance of early ART initiation. Support from husbands facilitated women's return to the clinic. Reminders were perceived as helpful but ineffectively employed. Staff identified lack of communication, difficulty in tracking, and referring women as barriers. Counseling messages should emphasize the importance of starting ART early. Clinics should focus on male partner involvement, case management, staff communication, and appointment reminders. Follow-up should be offered at multiple service points.

Evaluation of a 5-year programme to prevent mother-to-child transmission of HIV infection in Northern Uganda

Prevention of mother-to-child transmission (PMTCT) is essential in HIV/AIDS control. We analysed 2000-05 data from mother-infant pairs in our PMTCT programme in rural Uganda, examining programme utilization and outcomes, HIV transmission rates and predictors of death or loss to follow-up (LFU). Out of 19,017 women, 1,037 (5.5%) attending antenatal care services tested HIV positive. Of these, 517 (50%) enrolled in the PMTCT programme and gave birth to 567 infants. Before tracing, 303 (53%) mother-infant pairs were LFU. Reasons for dropout were infant death and lack of understanding of importance of follow-up. Risk of death or LFU was higher among infants with no or incomplete intrapartum prophylaxis (OR = 1.90, 95% CI 1.07-3.36) and of weaning age <6 months (OR 2.55, 95% CI 1.42-4.58), and lower in infants with diagnosed acute illness (OR 0.30, 95% CI 0.16-0.55). Mother-to-child HIV cumulative transmission rate was 8.3%, and 15.5% when HIV-related deaths were considered. Improved tracking of HIV-exposed infants is needed in PMTCT programmes where access to early infant diagnosis is still limited.

Combating HIV stigma in health care settings: what works?

The purpose of this review paper is to provide information and guidance to those in the health care setting about why it is important to combat HIV-related stigma and how to successfully address its causes and consequences within health facilities. Research shows that stigma and discrimination in the health care setting and elsewhere contributes to keeping people, including health workers, from accessing HIV prevention, care and treatment services and adopting key preventive behaviours.

Studies from different parts of the world reveal that there are three main immediately actionable causes of HIV-related stigma in health facilities: lack of awareness among health workers of what stigma looks like and why it is damaging; fear of casual contact stemming from incomplete knowledge about HIV transmission; and the association of HIV with improper or immoral behaviour.

To combat stigma in health facilities, interventions must focus on the individual, environmental and policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will likely result in long-lasting benefits for both health workers and HIV-positive patients. The existence of tested stigma-reduction tools and approaches has moved the field forward. What is needed now is the political will and resources to support and scale up stigma-reduction activities throughout health care settings globally.

A comparison of HIV stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings

What accounts for differences in HIV stigma across different high prevalence settings? This study was designed to examine HIV stigma and discrimination in five high prevalence settings. Qualitative data were collected as part of the U.S. National Institute of Mental Health (NIMH) Project Accept, a multi-site community randomized trial of community-based HIV voluntary counseling and testing. In-depth interviews were conducted with 655 participants in five sites, four in Sub-Saharan Africa and one in Southeast Asia. Interviews were conducted in the local languages by trained research staff. Data were audiotaped, transcribed, translated, coded and computerized for thematic data analysis. Participants described the stigmatizing attitudes and behaviors perpetuated against people living with HIV/AIDS (PLWHA). The factors that contribute to HIV stigma and discrimination include fear of transmission, fear of suffering and death, and the burden of caring for PLWHA. The family, access to antiretrovirals and other resources, and self-protective behaviors of PLWHA protected against HIV stigma and discrimination. Variation in the availability of health and socioeconomic resources designed to mitigate the impact of HIV/AIDS helps explain differences in HIV stigma and discrimination across the settings. Increasing access to treatment and care resources may function to lower HIV stigma, however, providing services is not enough. We need effective strategies to reduce HIV stigma as treatment and care resources are scaled up in the settings that are most heavily impacted by the HIV epidemic.

Breast milk as the "water that supports and preserves life"--socio-cultural constructions of breastfeeding and their implications for the prevention of mother to child transmission of HIV in sub-Saharan Africa

OBJECTIVES

Complementary breastfeeding represents an important source of risk of HIV infection for infants born to HIV positive mothers. The World Health Organisation recommends that infants born to HIV positive mothers receive either replacement feeding or exclusive breastfeeding (EBF) followed by early weaning. Beyond the clinical and epidemiological debate, it remains unclear how acceptable and feasible the two options are for rural populations in sub-Saharan Africa. This qualitative study aims to fill this gap in knowledge by exploring both the socio-cultural construction and the practice of breastfeeding in the Nouna Health District, rural Burkina Faso.

METHODS

Information was collected through 32 individual interviews and 3 focus group discussions with women of all ages, and 6 interviews with local guérisseurs.

RESULTS

The findings highlight that breastfeeding is perceived as central to motherhood, but that women practice complementary, rather than exclusive, breastfeeding. The findings also indicate that women recognise both the nutritional value of breast milk and its potential to act as a source of disease transmission.

CONCLUSIONS

The findings suggest that given the socio-cultural importance attributed to breastfeeding and the prevailing poverty, it may be more acceptable and more feasible to promote EBF followed by early weaning than replacement feeding. A set of operational strategies are proposed to favour the prevention of mother to child transmission of HIV in the respect of the local socio-cultural setting.

Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward

Although stigma is considered a major barrier to effective responses to the HIV/AIDS epidemic, stigma reduction efforts are relegated to the bottom of AIDS programme priorities. The complexity of HIV/AIDS-related stigma is often cited as a primary reason for the limited response to this pervasive phenomenon. In this paper, we systematically review the scientific literature on HIV/AIDS-related stigma to document the current state of research, identify gaps in the available evidence and highlight promising strategies to address stigma. We focus on the following key challenges: defining, measuring and reducing HIV/AIDS-related stigma as well as assessing the impact of stigma on the effectiveness of HIV prevention and treatment programmes. Based on the literature, we conclude by offering a set of recommendations that may represent important next steps in a multifaceted response to stigma in the HIV/AIDS epidemic.

Factors influencing teen mothers' enrollment and participation in prevention of mother-to-child HIV transmission services in Limpopo Province, South Africa

In this article, we examine barriers to HIV testing uptake and participation in prevention of mother-to-child HIV transmission (PMTCT) services among adolescent mothers aged 15 to 19 years in rural and urban Limpopo Province, South Africa. We used the narrative research method involving key informants constructing typical case studies of adolescent experiences with HIV testing and entry into PMTCT. Case studies formed the basis of a community-based questionnaire and focus group discussions with adolescent mothers. Client-counselor dynamics during pretest counseling were pivotal in determining uptake and participation, and counselor profile strongly influenced the nature of the interaction. Other factors found to influence adherence to PMTCT recommendations included HIV and early premarital pregnancy stigma, fear of a positive test result, and concerns over confidentiality and poor treatment by health care providers. Adolescents described elaborate strategies to avoid HIV disclosure to labor and delivery staff, despite knowing this would mean no antiretroviral therapy for their newborn infants. Theoretical, methodological, and programmatic implications of study findings are also discussed.

Emotional development and nutritional status of HIV/AIDS orphaned children aged 6-12 years old in Thailand

OBJECTIVE

To explore the emotional development and nutritional status of HIV/AIDS orphans by their infection status.

METHODS

A community-based cross-sectional survey was conducted during January and December 2005 in four provinces and Bangkok Metropolis where the prevalence of HIV/AIDS among pregnant women was high. The study population consisted of 388 HIV/AIDS orphans who were maternal or paternal or double orphans aged 6-12 years old. The orphans' main caregivers gave informed consent to the project and assessed the emotional development of their orphaned children. The children were measured for weight, height, and emotional development by standard instruments. They were divided into three groups regarding their HIV/AIDS infection status reported by their caregivers: infected, non-infected, and unknown. The chi(2) test was used to determine the association between nutritional status and infection status.

RESULTS

Regarding HIV/AIDS infected children, 19.1% were infected, 57.5% were not infected, and 23.4% were unknown. The main caregivers of all types of orphans were grandparents. Only 13.7% of infected orphans lived with their mothers. Most caregivers were females and more than 40 years old. Infected orphans had mean scores of overall emotional development and for each domain less than other groups. The mean scores of self-control and quick recovery were significantly different between infected and non-infected groups (P-value < 0.05). Nearly 50% of infected orphans were rather short and approximately 42% were under weight and light. The findings revealed a significant association between height for age, weight for age and infection status of orphans at a P-value of <0.001.

CONCLUSIONS

Orphanhood itself is a vulnerable status and HIV/AIDS infected orphans are most vulnerable. Acceptable and friendly services for orphans and their families are crucial. The services should continue and protect stigmatization.

Preventing Mother-to-Child HIV Transmission Among South African Adolescents

Although prevention of mother-to-child HIV transmission (PMTCT) programs are predicated on maternal behavior change, little is known about sociocultural factors affecting maternal—child care practices in this arena. The authors used narrative methods (key informant workshops, questionnaires, focus groups, and case study analysis) to explore how sociocultural context shapes adolescent mothers' ability to adhere to programmatic recommendations in rural and urban South Africa. The study aims were to understand the extent to which mothers' decisions are borne out in PMTCT-related practices and to identify contextual elements that affect the link between individual resolutions and action. The results revealed rural adolescents as less likely than urbanites to successfully implement most PMTCT-related practices. HIV stigma, family decision making, and cultural norms surrounding infant feeding hampered mothers' efforts to implement practices that would decrease the risk for infant infection. Barriers to behavior change were analyzed along four domains: history, culture, gender, and power. Methodological aspects and programmatic implications are discussed.

Les défis soulevés par la prévention de la transmission mère-enfant du VIH en Afrique

HIV (human immunodeficiency virus) is the leading cause of infant mortality in Africa where 1700 children are infected each day, principally by mother-to-child transmission. Prevention of this risk is therefore a public health priority. Considerable progress has been made in the past 10 years in preventing the risk of mother-to-child transmission in the peripartum period in Africa: short antiretroviral regimens during the third trimester of pregnancy can reduce transmission rates to less than 5%. Breast-feeding, which is widespread and prolonged in Africa, causes many HIV infections and thus reduces the efficacy of peripartum interventions. Interventions that offer alternatives to prolonged breast-feeding and are both socially acceptable and safe for the infant can effectively reduce the risk of postnatal HIV transmission. But operational implementation of these postnatal interventions remains complex. Use of antiretroviral agents as prophylaxis for mother and child during the breast-feeding period and clinical management of breast-feeding mothers with combined antiretroviral treatments offer hope that the risk of postnatal HIV transmission can be reduced, but the effectiveness and safety of these interventions still need to be assessed.

Modeling HIV transmission risk among Mozambicans prior to their initiating highly active antiretroviral therapy

Understanding sexual behavior and assessing transmission risk among people living with HIV-1 is crucial for effective HIV-1 prevention. We describe sexual behavior among HIV-positive persons initiating highly active antiretroviral therapy (HAART) in Beira, Mozambique. We present a Bernoulli process model (tool available online) to estimate the number of sexual partners who would acquire HIV-1 as a consequence of sexual contact with study participants within the prior three months. Baseline data were collected on 350 HAART-naive individuals 18-70 years of age from October 2004 to February 2005. In the three months prior to initiating HAART, 45% (n = 157) of participants had sexual relationships with 191 partners. Unprotected sex occurred in 70% of partnerships, with evidence suggesting unprotected sex was less likely with partners believed to be HIV-negative. Only 26% of the participants disclosed their serostatus to partners with a negative or unknown serostatus. Women were less likely to report concurrent relationships than were men (21 versus 66%; OR 0.13; 95%CI: 0.06, 0.26). Given baseline behaviors, the model estimated 23.2 infections/1,000 HIV-positive persons per year. The model demonstrated HAART along with syphilis and herpes simplex virus type 2 (HSV-2) treatment combined could reduce HIV-1 transmission by 87%; increasing condom use could reduce HIV-1 transmission by 67%.

Acceptability of Formula-Feeding to Prevent HIV Postnatal Transmission, Abidjan, Côte d'Ivoire

OBJECTIVE

To describe the maternal acceptability of formula-feeding proposed to reduce postnatal HIV transmission in Abidjan, Côte d'Ivoire.

METHODS

Each consenting HIV-infected pregnant women, age > or =18 years, who received a perinatal antiretroviral prophylaxis was eligible. Two hierarchical infant-feeding options were proposed antenatally: exclusive formula-feeding or short-term exclusive breast-feeding. Formula-feeding was provided free up to age 9 months. Determinants of acceptability were analyzed using a logistic regression. Formula-feeding failure was defined as having breast-fed one's child at least once.

RESULTS

Between March 2001 and March 2003, 580 women delivered: 97% expressed their infant-feeding choice before delivery; 53% chose formula-feeding. Significant prenatal determinants for refusing formula-feeding were: living with her partner, being Muslim, having a low educational level, being followed in one of the study sites, having not disclosed her HIV status, and having been included within the first 6 months of the project. Among the 295 mothers who formula-fed, the Kaplan-Meier probability of success of the formula-feeding option was 93.6% at Day 2 (95% confidence interval [CI]: 90.7% to 96.3%) and 84.2% at 12 months (95% CI: 79.9% to 88.5%): 46 of 295 (15.6%) women breast-fed at least once, of whom 41% temporarily practiced mixed-feeding at Day 2 because of social stigma or newborn poor health.

CONCLUSIONS

In settings with general access to clean water, structured antenatal counseling, and sustained provision of free formula, slightly over half of HIV-infected women chose to artificially feed their newborn infant. Low mixed-feeding rates were observed. This social acceptability must be balanced with mother-child long-term health outcomes to guide safe recommendations on infant-feeding among HIV-infected women in African urban settings.