‘My fear is to fall in love again…’ How HIV-positive African women survive in London

'HIV ended up in second place' - prioritizing social integration in the shadow of social exclusion: an interview study with migrants living with HIV in Sweden

BACKGROUND

Migrants are overrepresented among people living with HIV in Sweden as they often face conditions that increased their risk and vulnerability for HIV/STI infections prior, during or after migration. Yet, there is limited research on their experiences and perceptions of living with HIV in the Swedish context. This study aims to explore migrants' experiences of living with HIV in Sweden.

METHODS

This is a qualitative study based on in-depth interviews with 13 migrants from 11 countries living with HIV in Sweden. Interviews were analysed with thematic analysis using an intersectional perspective to explore the interactions of multiple social identities such as ethnicity, socio-economic status, gender, age, and sexual orientation that shape an individual's or group's experiences.

RESULTS

The analysis resulted in a main theme: 'Prioritizing social integration-HIV ends up in second place', which is based on four subthemes: 'Better opportunities in the new country than what the home country could offer', 'Better conditions for LGBTQI people than in the home country', 'Navigating a new system: linguistic and bureaucratic challenges' and 'Feeling like a second-class resident: racism, xenophobia and multiple discrimination'. The results suggest that migrants living with HIV in Sweden experience social integration as a greater challenge than HIV infection. Although the new country offers opportunities for better living conditions, many participants described being challenged in their daily life by linguistic and structural barriers in their encounters with public services. They are facing multiple discrimination simultaneously as migrants due to their multiple and intersecting identities (e.g. being non-white, foreigners/foreign-born and non-Swedish speakers), which is compounded by HIV status and thus limit their opportunities in the new country and too often result in an existence of exclusion.

CONCLUSION

The study shows that most of the challenges that migrants living with HIV face are related to their status as migrants rather than HIV status, which is often not known by the public or authorities. These challenges are similar, but still differ depending on social position, previous experiences, time since arrival and since diagnosis. This emphasizes the importance of both intersectional, intersectoral and multisectoral approaches to address reported issues.

Enduring stigma and precarity: A review of qualitative research examining the experiences of women living with HIV in high income countries over two decades

The lived experience of HIV for women remains poorly understood. In particular, there has been little attention to the consequences for women living with HIV (WLHIV) of changing social, epidemiological, biomedical and policy contexts, or to the implications of long-term treatment and aging for the current generation of HIV-positive women. We reviewed qualitative research with WLHIV in selected high-income countries (Australia, Canada, New Zealand, the UK and the USA) to identify the most prevalent experiences of HIV for women and trends over time. Our synthesis highlights the relative consistency of experiences of a diverse sample of WLHIV, particularly the enduring prevalence of gendered HIV-related stigma, sociostructural barriers to healthcare and support, and negative encounters with health professionals. We also identified gaps in knowledge. Understanding women's experiences, particularly their changing needs and strategies for coping as they live long-term with HIV, is key to effective support and services for WLHIV.

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review

Migrants in countries affiliated with the Organization for Economic Co-operation and Development (OECD) have a higher risk of acquiring HIV, experience delayed HIV diagnosis, and have variable levels of engagement with HIV care and treatment when compared to native-born populations. A systematic mixed studies review was conducted to generate a multilevel understanding of the barriers and facilitators affecting HIV Care Cascade steps for migrant people living with HIV (MLWH) in OECD countries. Medline, Embase, Scopus, CINAHL, and the Cochrane Library were searched on March 25, 2020. Screening, critical appraisal, and analysis were conducted independently by two authors. We used qualitative content analysis and the five-level Socio-Ecological Model (i.e., individual, interpersonal, organizational, community, and policy) to categorize barriers and facilitators. Fifty-nine studies from 17 OECD countries were included. MLWH faced similar barriers and facilitators regardless of their host country, ethnic and geographic origins, or legal status. Most barriers and facilitators were associated with the individual and organizational levels and centered around retention in HIV care and treatment. Adapting clinical environments to better address MLWH's competing needs via multidisciplinary models would address retention issues across OECD countries.

Situating adherence to medicines: The embodied practices and hinterlands of HIV antiretrovirals

Adherence to medicines tends to be envisaged as a matter of actors' reasoned actions, though there is increasing emphasis on situating adherence as a practice materialised in everyday routines. Drawing on the qualitative interview accounts of Black African women living with HIV in London, UK, we treat adherence to HIV medicines as not only situated in the practices of the immediate and everyday but also relating to a hinterland of historical and social relations. We move from accounts which situate adherence as an embodied matter of affect in the present, to accounts which locate adherence as a condition of precarity, which also trace to enactments of time and place in the past. Adherence is therefore envisaged as a multiple and fluid effect which is made-up in-the-now and in relation to a hinterland of practices which locate elsewhere.

Prevalence and factors associated with fertility desire among people living with HIV: A systematic review and meta-analysis

BACKGROUND

The fertility desire of people living with HIV (PLHIV) has been rising in the past decade. However, there are many studies among which the association remains controversial between the fertility desire of HIV-infected persons and antiretroviral therapy (ART), sex, marital status, and educational level.

METHODS

We performed a literature search of these meta-analyses in PubMed, the Cochrane Library, Web of Science and ScienceDirect in November 2019. We also reviewed references of eligible studies to complement the search. We used pooled odds ratios (ORs) and 95% confidence intervals (CIs) with a random-effects model and a fixed-effects model to estimate the association between fertility desire among PLHIV and ART, sex, age, marital status, educational level, and number of children. Subgroups with I square values (I2) and sensitivity analyses were performed to assess the heterogeneity and the stability of the overall ORs, respectively. We evaluated publication bias using Egger's test and a visual inspection of the symmetry in funnel plots.

RESULTS

In these meta-analyses 50 articles were included with 22,367 subjects. The pooled prevalence of fertility desire among PLHIV was estimated to be 42.04%. The pooled analyses showed that the fertility desire of PLHIV is associated with ART (OR = 1.11, 95% CI:1.00-1.23, P = 0.043), sex (OR = 1.51, 95% CI:1.10-2.09), age (OR = 2.65, 95% CI:2.24-3.14), marital status (OR = 1.34, 95% CI:1.08-1.66), educational level (OR = 0.85, 95% CI:0.73-1.00, P = 0.047) and the number of children (OR = 3.99, 95% CI:3.06-5.20). PLHIV who are on ART, are male, are younger than 30, are married/cohabiting, have received a secondary education or above, and are childless have a higher prevalence of fertility desire. The two factors of age and the number of children, in particular demonstrated a strong significant association with fertility desire. We found moderate heterogeneity in the meta-analyses of age and educational level and high heterogeneity in the meta-analyses of sex, marital status and number of children. Publication bias was detected in the meta-analyses of the association of fertility with sex and educational level.

CONCLUSION

This study demonstrates that the prevalence of fertility desire among HIV-infected people is 42.04%, and the fertility desire among PLHIV is associated with ART experience, sex, age, marital status, the number of children, and educational level. Since a majority of PLHIV are of reproductive age, it is necessary to support PLHIV in terms of their needs regarding reproductive decision-making. Through counseling and reproductive health care, further measures to prevent the horizontal and vertical transmission of HIV should be taken.

Love with HIV: A Latent Class Analysis of Sexual and Intimate Relationship Experiences Among Women Living with HIV in Canada

Love remains hidden in HIV research in favor of a focus on risk. Among 1424 women living with HIV in Canada, we explored (1) whether eight facets of sex and intimacy (marital status, sexual activity, physical intimacy, emotional closeness, power equity, sexual exclusivity, relationship duration, and couple HIV serostatus) may coalesce into distinct relationship types, and (2) how these relationship types may be linked to love as well as various social, psychological, and structural factors. Five latent classes were identified: no relationship (46.5%), relationships without sex (8.6%), and three types of sexual relationships-short term (15.4%), long term/unhappy (6.4%), and long term/happy (23.2%, characterized by equitable power, high levels of physical and emotional closeness, and mainly HIV-negative partners). While women in long-term/happy relationships were most likely to report feeling love for and wanted by someone "all of the time," love was not exclusive to sexual or romantic partners and a sizeable proportion of women reported affection across latent classes. Factors independently associated with latent class membership included age, children living at home, sexism/genderism, income, sex work, violence, trauma, depression, HIV treatment, awareness of treatment's prevention benefits, and HIV-related stigma. Findings reveal the diversity of women's experiences with respect to love, sex, and relationships and draw attention to the sociostructural factors shaping intimate partnering in the context of HIV. A nuanced focus on promoting healthy relationships and supportive social environments may offer a more comprehensive approach to supporting women's overall sexual health and well-being than programs focused solely on sexual risk reduction.

HIV Testing and Sexual Health Among Black African Men and Women in London, United Kingdom

Importance

Black African adults are disproportionately affected by HIV in the United Kingdom. Many within this population acquire HIV after migration or are diagnosed late. Data are needed to inform targeted interventions to increase HIV testing and prevention in this population.

Objective

To inform future HIV prevention strategies by estimating diagnosed and undiagnosed HIV infection and measuring changes in HIV testing rates in black African adults in London, United Kingdom.

Design, Setting, and Participants

This cross-sectional study used a self-completed survey conducted from September 20 to December 3, 2016. Questionnaires were linked to an optional, anonymous oral fluid HIV test and compared with data from a previous survey (2004). Respondents were recruited from social and commercial venues frequented by black African adults in London. Of 2531 individuals approached in 63 venues, 752 agreed to participate. Data were analyzed initially in March 2017 (as part of internal reporting) and again in August 2018.

Main Outcomes and Measures

Self-reported HIV testing within the past 5 years; diagnosed and undiagnosed HIV prevalence. Logistic regression examined factors associated with HIV testing by sex.

Results

In total, 292 women (median [interquartile range] age, 31 [25.0-41.5] years) and 312 men (median [interquartile range] age, 35 [25.0-41.5] years) were included in the analysis. More than half of men (159 [51.0%]) and women (154 [52.7%]) had been tested for HIV in the past 5 years. In multivariable analysis, HIV testing was associated with a range of factors in both sexes, including health service attendance, time in the United Kingdom, and sexually transmitted infection diagnosis. Increases in HIV testing in the past 5 years were observed between 2004 and 2016 for both sexes. In the 2016 sample, 219 of 235 women (93.2%) and 206 of 228 men (90.4%) tested HIV negative. Among those testing positive, 56.3% of women (9 of 16) and 40.9% of men (9 of 22) self-reported as HIV negative or untested, indicating they were living with undiagnosed HIV. A fifth of women (20.7%) and 25.0% of men reported condomless last sex with a partner of different or unknown HIV status in the past year.

Conclusions and Relevance

Despite efforts to increase HIV testing, uptake in black African communities in London remains modest. This study identified a large fraction of undiagnosed infection-greater than other at-risk populations-suggesting that the prevention and care needs of this group are not adequately met.

Assessing Stigma, Disclosure Regret and Posttraumatic Growth in People Living with HIV

Posttraumatic growth after a diagnosis of HIV is positively associated with adjustment, yet stigma and disclosure regret are negatively associated with adjustment. Research into whether posttraumatic growth is experienced while perceiving stigma and disclosure regret is still growing. This study aimed to determine whether posttraumatic growth maintains a positive relation with life satisfaction after controlling for disclosure regret and perceived stigma. Using a cross-sectional design, a questionnaire measuring life satisfaction, health status, depression, posttraumatic growth, disease severity, perceived stigma, disclosure regret, and demographical information was completed by 73 people living with HIV (PLWH). Results showed that all participants had disclosed to at least one person. Regression results showed that after controlling for other variables, including stigma and disclosure regret, posttraumatic growth was positively associated with life satisfaction. The importance of the relation of posttraumatic growth with subjective measures of adjustment may be important for interventions aimed at supporting PLWH.

Prevalence and factors associated with the use of traditional medicines among human immunodeficiency virus and acquired immunodeficiency syndrome patients in Sokoto, Nigeria

Background

In resource-scarce settings like Nigeria, access to conventional drugs and antiretroviral therapy (ART) is highly limited, hence the resort to use of traditional herbal medicine by a significant number of people living with human immunodeficiency virus and acquired immunodeficiency syndrome (HIV/AIDS) (PLWHAs). Traditional medicine (TM) continues to provide health coverage for most of the people in developing countries, and it is equally becoming increasingly popular in western countries.

Aim

This study aims to present the status and use of TM and determine the factors associated with its use among patients with HIV/AIDS on highly active ART in a tertiary health institution in Sokoto, Northwest Nigeria.

Methodology

This was a descriptive, cross-sectional study involving HIV/AIDS patients attending antiretroviral treatment center of the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Nigeria. The study population comprised PLWHAs attending the ART clinic of the hospital (UDUTH). A total of 271 respondents were recruited into the study and administered a set of pretested structured questionnaire. Ethical approval for this study was obtained from the ethical committee of the teaching hospital.

Results

Only 11 (4.2%) of the respondents had used TM before, of whom 9 (5%) were females and 2 (2.7%) were males with P = 0.399. Only one of the respondents had side effects following the use of TM, and the most common reason for the use of TM was as a result of too much weight loss.

Conclusion

Although the use of TM among the study participants in Sokoto was low, there is need to educate PLWHAs about the possible risks of interactions following the concurrent use of TM and ART.

"That's not me anymore": Resistance strategies for managing intersectional stigmas for women with substance use and incarceration histories

Significant previous research has focused on how individuals experience stigma when interacting with the public sphere and service agencies; the purpose of this grounded theory study is to explore how formerly incarcerated mothers with histories of substance use experience stigmas from their intimate relationships with family and romantic partners. Using an intersectionality lens, this study reveals that the women perceived multiple stigmas due to their previous substance use, incarceration, and other addiction-related behaviors that challenged their roles as mothers and romantic partners. Compounding the behavioral-related stigmas were race and class-based stereotypes of black criminality that also challenged women's ability to embody key motherhood and womanhood roles. As a result, the women employed resistance strategies to safeguard against stigma and preserve their recovery. The implications for practice underscore the significance of addressing personal experiences of stigma, complex relational dynamics, and understanding the needs of support systems that are also shaped by the women's cycles of incarceration and illness.

A Systematic Review of HIV Serostatus Disclosure Among African Immigrants in Europe

As the human immunodeficiency virus continues to devastate large parts of Africa, particularly the Sub-Saharan region, the number of immigrants migrating from these areas to European nations continues to grow. African men and women leave their countries for Europe because of armed conflicts, unemployment, or poverty. Thus, these migration patterns combined with newly contracted infections have resulted in a large and growing number of HIV-positive diagnoses among African immigrants living in Europe. Using the disclosure process model, this systematic review examines the reasons for HIV status disclosure and nondisclosure among African immigrants residing in Europe. PubMed, PsycINFO, Embase, Global Health, and Web of Science were searched. Bibliographies of retrieved studies were also reviewed for other relevant citations. Studies were eligible if they: (1) focused on HIV-positive immigrants from SSA residing in Europe; and (2) described or measured HIV status disclosure. Out of 166 articles found, a total of 17 articles and 1 brief report met the inclusion criteria. Factors such as stigma and social implications of disclosure contribute to avoidance goals leading to nondisclosure while approach goals or disclosure reasons were found to include health status and behaviors such as seeking support, and helping others. The findings highlight the importance of understanding the avoidance and approach goals involved in HIV status disclosure among African immigrants in Europe. Interventions and future research directed at increasing HIV disclosure among African immigrants in Europe should move beyond individual-level to consider multilevel factors including country-specific social behaviors.

INTEGRATING THE ROLES OF STAKEHOLDERS IN PREVENTING THE HIV/AIDS TRANSMISSION IN EAST JAVA, INDONESIA

HIV/AIDS prevention is very important and absolutely necessary. HIV transmission is now entering a fairly alarming level, in which people with HIV/AIDS in certain subpopulations are emerging. Special steps and resources are thus needed to cope with the condition. There are some phenomena potentially encourage HIV transmissions, such as the increasingly common free sex, homosexuality, the use of unsafe and unsterile syringes in narcotics consumption, commercial sex workers and various high-risk sexual activities. One of the crucial concerns that arises when sending prostitutes back to their hometowns without any coordinated and holistic mechanism is that the prostitutes may cause the spreading of HIV/AIDS in their hometowns. The research objective is to provide the material (input) how the prostitutes themselves may cause the spreading of HIV/AIDS. The research employed descriptive method with a qualitative approach. The results showed that the implementation and the role division in the closure have been highly coordinated and holistic. The leading sector in the role division is the Social Welfare epartment of the Government in Surabaya. In terms of health aspects for the former prostitutes sent back to their hometowns, there has been no policies related to medical screening designed to identify the disease early. Screening is very important for early diagnosis during the post-closure phase. The screening mechanism is that the Provincial Health Department has to optimize the monitoring, coordination, cooperation, agreements and partnerships with stakeholders such as the Local Health Department and the National/Provincial/Distric AIDS Commission, NGOs that are concerned with the problems of HIV-AIDS, international organizations, professional organizations, community leaders, religious leaders and universities.

Factors influencing reproductive choices of HIV positive individuals attending primary health care facilities in a South African health district

BACKGROUND

There is global recognition of the reproductive health rights of people living with HIV (PLHIV). The aim of this research study was to explore the reproductive choices, and the factors influencing these choices, of HIV positive patients attending primary health care (PHC) facilities in the Ekurhuleni health district of the Gauteng Province of South Africa.

METHODS

During 2013, a cross-sectional survey was conducted in the Ekurhuleni health district. At each of three randomly selected community health centres, a random sample of HIV positive patients was selected. After informed consent was obtained, trained fieldworkers administered a structured questionnaire that elicited information on socio-demographics, reproductive choices and knowledge of reproductive options. Survey data were analysed using STATA® 13.

RESULTS

The majority of survey participants (n = 430) were female (70%) and unemployed (57%). The mean age of participants was 36.4 years (SD 8.6): 40.8 years (SD 8.7) for men and 34.5 years (SD7.8) for women. Among survey participants, 46% expressed a desire for children (95% CI: 41.4-50.9). In the multiple logistic regression analysis, predictors of desire for children were age less than 49 years, marriage or living together, and no biological children. The odds of wanting children was 16.48 [95% CI: 5.94-45.74] times higher for PLHIV without children, compared with those with two or more children, while for those less than 25 years, the odds of wanting children was 0.78 [95% CI: 0.23-2.59] compared with those older than 50 years. The PLHIV knowledge on the available reproductive options was limited, with the majority relying on the guidance of the health workers.

CONCLUSION

Health care providers at PHC level should be educated to address the reproductive health needs of PLHIV. These aspects should be reflected in provincial and national health policies.

The Experience of Antiretroviral Treatment for Black West African Women who are HIV Positive and Living in London: An Interpretative Phenomenological Analysis

Antiretroviral therapy (ART) offers a powerful intervention in HIV but effectiveness can be compromised by inadequate adherence. This paper is a detailed examination of the experience of medication in a purposively selected group of people living with HIV. In-depth interviews were conducted with 10 HIV positive, West African women of black heritage living in London, UK. This group was of interest since it is the second largest group affected by HIV in the UK. Interviews were subjected to interpretative phenomenological analysis, an idiographic, experiential, qualitative approach. The paper details the women's negative experience of treatment. ART can be considered difficult and unrelenting and may be disconnected from the women's sense of health or illness. Participants' social context often exacerbated the difficulties. Some reported an improvement in their feelings about the medication over time. These findings point to some intrinsic and social motivators which could act as spurs to adherence.

HIV-related stigma among African, Caribbean, and Black youth in Windsor, Ontario

HIV-related stigma has been shown to undermine prevention, care, treatment, and the well-being of people living with HIV. A disproportion burden of HIV infection, as well as elevated levels of HIV-related stigma, is evidenced in sub-Saharan African (SSA) and African-diasporic populations. This study explores factors that influence HIV-related stigma among 16- to 25-year-old youth residing in a Canadian city who identify as African, Caribbean, or Black. Stigma, as rooted in cultural norms and beliefs and related social institutions, combined with insights from research on stigma in SSA and African-diasporic populations, guided the development of a path analytic structural equation model predicting levels of HIV-related stigmatizing attitudes. The model was tested using survey responses of 510 youth to estimate the direct and indirect influences of ethno-religious identity, religious service attendance, time in Canada, HIV/AIDS knowledge, HIV-testing history, sexual health service contact, and gender on HIV-related stigma. Statistically significant negative associations were found between levels of stigma and knowledge and HIV-testing history. Ethno-religious identity and gender had both direct and indirect effects on stigma. African-Muslim participants had higher levels of stigma, lower knowledge, and were less likely to have been tested for HIV infection than other ethno-religious groups. Male participants had higher levels of stigma and lower knowledge than women. Time in Canada had only indirect effects on stigma, with participants in Canada for longer periods having higher knowledge and less likely to have been tested than more recent arrivals. While the strength of the effect of knowledge on stigmatizing attitudes in this research is consistent with other research on stigma and evaluations of stigma-reduction programs, the path analytic results provide additional information about how knowledge and HIV-testing function as mediators of non-modifiable characteristics such as gender, ethnicity, religion, and time in a country.

When Debility Provides a Future: Preventing Vertical Transmission of HIV

In this article we investigate the way in which viral load assays are used to assess the viruses of Human Immunodeficiency Virus (HIV)-positive pregnant women who are cared for in an HIV-specialist antenatal clinic in London. One of the viral load assays has been made more sensitive to subtypes of the virus that are considered to be local, possibly reading the viruses of those who have ‘foreign’ subtypes as undetectable. Consequently, the patient might not be offered the kind of care needed to prevent transmission of HIV, as her body is not recognised as sufficiently debilitated. Thus, being identified as a debilitated body in this setting facilitates the prevention of vertical transmission of HIV and the management of the HIV-positive pregnant patient's virus. Further to this, we argue that in our example, having a debilitated body as constructed by the viral load assay is thus a ‘privilege’ that is accorded to HIV-positive persons depending on the geographic origin of their virus. Using Karen Barad's agential realism, we argue that the manner in which HIV is read through the viral load assay constructs a specific woman/foetus/HIV phenomenon. The specificity of this phenomenon directly impacts on the course of care, opening up or foreclosing the possibility of her child having a future free from HIV.

Being diagnosed with a sexually transmitted infection (STI): sources of support for young women

BACKGROUND

Sexually transmitted infections (STIs) are prevalent throughout the world with the rate of these infections increasing on a daily basis. STI acquisition has the ability to cause personal adversity and elicit feelings of stigma and shame.

AIM

The aim of this paper is to report on the sources of support young women who acquired STIs drew on to overcome their associated adversity.

METHODS

This study utilised a feminist qualitative methodology.

FINDINGS

Findings revealed that the women drew on both personal and anonymous sources of support.

CONCLUSION

Nurses and other health-care professionals need to be equipped with knowledge and strategies to promote personal wellbeing and minimise the adversity felt among people having acquired these infections.

Intimacy versus isolation: a qualitative study of sexual practices among sexually active HIV-infected patients in HIV care in Brazil, Thailand, and Zambia

The success of global treatment as prevention (TasP) efforts for individuals living with HIV/AIDS (PLWHA) is dependent on successful implementation, and therefore the appropriate contribution of social and behavioral science to these efforts. Understanding the psychosocial context of condomless sex among PLWHA could shed light on effective points of intervention. HPTN 063 was an observational mixed-methods study of sexually active, in-care PLWHA in Thailand, Zambia, and Brazil as a foundation for integrating secondary HIV prevention into HIV treatment. From 2010–2012, 80 qualitative interviews were conducted with PLWHA receiving HIV care and reported recent sexual risk. Thirty men who have sex with women (MSW) and 30 women who have sex with men (WSM) participated in equal numbers across the sites. Thailand and Brazil also enrolled 20 biologically-born men who have sex with men (MSM). Part of the interview focused on the impact of HIV on sexual practices and relationships. Interviews were recorded, transcribed, translated into English and examined using qualitative descriptive analysis. The mean age was 25 (SD = 3.2). There were numerous similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Participants had a high degree of HIV transmission risk awareness and practiced some protective sexual behaviors such as reduced sexual activity, increased use of condoms, and external ejaculation. Themes related to risk behavior can be categorized according to struggles for intimacy and fears of isolation, including: fear of infecting a sex partner, guilt about sex, sexual communication difficulty, HIV-stigma, and worry about sexual partnerships. Emphasizing sexual health, intimacy and protective practices as components of nonjudgmental sex-positive secondary HIV prevention interventions is recommended. For in-care PLWHA, this approach has the potential to support TasP. The overlap of themes across groups and countries indicates that similar intervention content may be effective for a range of settings.

A scoping review and thematic analysis of social and behavioural research among HIV-serodiscordant couples in high-income settings

BACKGROUND

While HIV incidence has stabilized in many settings, increases in health and wellbeing among many people living with HIV/AIDS suggest that the number of HIV-serodiscordant relationships is growing. Given the deficit of reviews addressing social and behavioural characteristics of HIV-serodiscordant couples within high-income settings, our objective was to understand the scope of the published literature, identify evidence gaps, and suggest future research needs.

METHODS

Ten electronic databases were searched. Studies were included if they were reported in English, used primary data, were from the combination antiretroviral (cART) era (>1996), reported on social or behavioural aspects, included any fraction of primary (i.e., stable) relationships, and were conducted in high-income settings. Studies that identified their unit of analysis as either the dyad or individual member of the couple were included. Studies were coded according to a thematic framework.

RESULTS

Included studies (n = 154) clustered into eight themes: risk behaviours (29%), risk management (26%), reproductive issues (12%), relationship quality (9%), serostatus disclosure (7%), adherence to antiretroviral therapy (7%), vulnerability (5%), and social support (3%). The proportion of studies conducted among heterosexual couples, same-sex male couples, and mixed cohorts were 42%, 34%, and 24%, respectively. Most studies (70%) were conducted in the United States, 70% of all studies were quantitative (including interventions), but only one-third were focused on couples (dyads) where both partners are recruited to a study. Over 25% of studies focused on sexual risk among same-sex male couples.

CONCLUSIONS

Future research efforts should focus on the interrelationship of risk management strategies and relationship quality, social determinants of health and wellbeing, HIV testing, vulnerable populations, reproductive issues among same-sex couples, disclosure of serodiscordant status to social networks, dyadic studies, population-based studies, and interventions to support risk management within couples. Additional population-based studies and studies among marginalized groups would be helpful for targeting research and interventions to couples that are most in need. As HIV-positive partners are typically the link to services and research, innovative ways are needed for reaching out to HIV-negative partners. Our review suggests that significantly more research is needed to understand the social and behavioural contexts of HIV-serodiscordant relationships.

Engaging new migrants in infectious disease screening: a qualitative semi-structured interview study of UK migrant community health-care leads

Migration to Europe - and in particular the UK - has risen dramatically in the past decades, with implications for public health services. Migrants have increased vulnerability to infectious diseases (70% of TB cases and 60% HIV cases are in migrants) and face multiple barriers to healthcare. There is currently considerable debate as to the optimum approach to infectious disease screening in this often hard-to-reach group, and an urgent need for innovative approaches. Little research has focused on the specific experience of new migrants, nor sought their views on ways forward. We undertook a qualitative semi-structured interview study of migrant community health-care leads representing dominant new migrant groups in London, UK, to explore their views around barriers to screening, acceptability of screening, and innovative approaches to screening for four key diseases (HIV, TB, hepatitis B, and hepatitis C). Participants unanimously agreed that current screening models are not perceived to be widely accessible to new migrant communities. Dominant barriers that discourage uptake of screening include disease-related stigma present in their own communities and services being perceived as non-migrant friendly. New migrants are likely to be disproportionately affected by these barriers, with implications for health status. Screening is certainly acceptable to new migrants, however, services need to be developed to become more community-based, proactive, and to work more closely with community organisations; findings that mirror the views of migrants and health-care providers in Europe and internationally. Awareness raising about the benefits of screening within new migrant communities is critical. One innovative approach proposed by participants is a community-based package of health screening combining all key diseases into one general health check-up, to lessen the associated stigma. Further research is needed to develop evidence-based community-focused screening models - drawing on models of best practice from other countries receiving high numbers of migrants.

HIV disclosure and nondisclosure among migrant women from sub-Saharan Africa living in Switzerland

No study to date has focused specifically on the reasons for and against disclosure of HIV-positive status among sub-Saharan migrant women. Thirty HIV-positive women from 11 sub-Saharan countries living in French-speaking Switzerland participated in semi-structured individual interviews. The reasons women reported for disclosure or nondisclosure of their HIV serostatus were classified into three categories: social, medical, and ethical. The women identified the stigma associated with HIV as a major social reason for nondisclosure. However, this study identifies new trends related to disclosure for medical and ethical reasons. Being undetectable played an important role in the life of sub-Saharan migrant women, and analysis revealed their medical reasons for both disclosure and nondisclosure. Disclosure to new sexual partners occurred when women had a more positive perception about HIV and when they believed themselves to be in a long-term relationship. Women reported nondisclosure to family members when they did not need help outside the support provided by the medical and social fields. The results on ethical reasons suggested that challenging stigma was a reason for disclosure. Since the women' perceptions on HIV changed when they came to see it as a chronic disease, disclosure occurred in an attempt to normalize life with HIV in their communities in migration and to challenge racism and discrimination. Our findings can help health providers better understand the communication needs of sub-Saharan migrant women with respect to HIV/AIDS and sexuality and offer them adequate disclosure advice that takes into account migration and gender issues.

How does HIV affect the reproductive choices of women of childbearing age?

The majority of women living with HIV are of childbearing age and many of these women wish to have a family. As a result of advances in the treatment and management of HIV, more reproductive opportunities are now available to this group. However, women living with HIV may still require education and guidance in a range of reproductive situations, including avoiding pregnancy, seeking fertility treatment or having a child. HIV physicians should be aware of recent data and guidance on these situations--including areas where more data are required--and consider them when deciding on appropriate management for their patients.

HIV among immigrants living in high-income countries: a realist review of evidence to guide targeted approaches to behavioural HIV prevention

BACKGROUND

Immigrants from developing and middle-income countries are an emerging priority in HIV prevention in high-income countries. This may be explained in part by accelerating international migration and population mobility. However, it may also be due to the vulnerabilities of immigrants including social exclusion along with socioeconomic, cultural and language barriers to HIV prevention. Contemporary thinking on effective HIV prevention stresses the need for targeted approaches that adapt HIV prevention interventions according to the cultural context and population being addressed. This review of evidence sought to generate insights into targeted approaches in this emerging area of HIV prevention.

METHODS

We undertook a realist review to answer the research question: 'How are HIV prevention interventions in high-income countries adapted to suit immigrants' needs?' A key goal was to uncover underlying theories or mechanisms operating in behavioural HIV prevention interventions with immigrants, to uncover explanations as how and why they work (or not) for particular groups in particular contexts, and thus to refine the underlying theories. The realist review mapped seven initial mechanisms underlying culturally appropriate HIV prevention with immigrants. Evidence from intervention studies and qualitative studies found in systematic searches was then used to test and refine these seven mechanisms.

RESULTS

Thirty-four intervention studies and 40 qualitative studies contributed to the analysis and synthesis of evidence. The strongest evidence supported the role of 'consonance' mechanisms, indicating the pivotal need to incorporate cultural values into the intervention content. Moderate evidence was found to support the role of three other mechanisms - 'understanding', 'specificity' and 'embeddedness' - which indicated that using the language of immigrants, usually the 'mother tongue', targeting (in terms of ethnicity) and the use of settings were also critical elements in culturally appropriate HIV prevention. There was mixed evidence for the roles of 'authenticity' and 'framing' mechanisms and only partial evidence to support role of 'endorsement' mechanisms.

CONCLUSIONS

This realist review contributes to the explanatory framework of behavioural HIV prevention among immigrants living in high-income countries and, in particular, builds a greater understanding of the suite of mechanisms that underpin adaptations of interventions by the cultural context and population being targeted.

Resilience among asylum seekers living with HIV

Background

A small body of evidence demonstrates the challenges faced by migrant communities living with HIV but has yet to consider in-depth the experience of asylum seekers whose residency status is undetermined. The overall aim of our study was to explore the experiences of those who are both living with HIV and seeking asylum. This paper focuses on the stressors precipitated by the HIV diagnosis and by going through the asylum system; as well as participants’ resilience in responding to these stressors and the consequences for their health and wellbeing.

Methods

We conducted an ethnographic study. Fieldwork took place in the UK between 2008–2009 and included: 350 hours of observation at voluntary services providing support to black and minority ethnic groups living with HIV; 29 interviews and four focus group discussions with those who were seeking asylum and living with HIV; and 15 interviews with their health and social care providers. Data were analysed using the constant comparative method.

Results

There were three main stressors that threatened participants’ resilience. First, migration caused them to leave behind many resources (including social support). Second, stigmatising attitudes led their HIV diagnosis to be a taboo subject furthering their isolation. Third, they found themselves trapped in the asylum system, unable to influence the outcome of their case and reliant on HIV treatment to stay alive. Participants were, however, very resourceful in dealing with these experiences. Resilience processes included: staying busy, drawing on personal faith, and the support received through HIV care providers and voluntary organisations. Even so, their isolated existence meant participants had limited access to social resources, and their treatment in the asylum system had a profound impact on perceived health and wellbeing.

Conclusions

Asylum seekers living with HIV in the UK show immense resilience. However, their isolation means they are often unable to deal with their treatment in the asylum system, with negative consequences for their perceived health and wellbeing.

Disclosure experience in a convenience sample of Quebec-born women living with HIV: a phenomenological study

BACKGROUND

In Canada, there has been a considerable increase in the number of women infected with the human immunodeficiency virus (HIV). Within a stigmatized social context, disclosure of HIV positivity is still a prevailing concern among women. Little is known about the global understanding of how French-speaking, Quebec-born women living with HIV, live their serostatus disclosure experience. The aim of this qualitative study is to describe and understand the disclosure experience of these women.

METHODS

We conducted semi-structured interviews with seven women. A convenience sample of French-speaking, Quebec-born women was chosen because they all responded to the criteria of wishing to share their disclosure experience. The mean age of the participants was 46 years old (SD±12). They lived with HIV for an average of 10 years; time since diagnosis varied from 8 months to 23 years. Two out of four mothers had given birth to HIV positive children. Data analysis proposed by van Manen was performed to discover the essential themes of the experience.

RESULTS

Seven themes were identified to understand the experience of disclosure in women: 1) Respecting for self and confidants; 2) Feeling apprehension; 3) Exercising control to ensure protection; 4) Deliberately engaging in a process of disclosure/non-disclosure; 5) Exposing oneself to stigma and social exclusion; 6) Suffering internally; and 7) Benefitting from the positive effects of one's decision. For these women, disclosing their HIV status meant: Living the ambivalence of a paradoxical process of revealing/concealing, in a state of profound suffering, exacerbated by stigma, while also being enriched by the benefits attained.

CONCLUSIONS

Understanding the experience of disclosure in WLHIV is important to guide actions in the practice to support and accompany these women in their unique reality. Health professionals have to broaden their role and work on individual, interpersonal, inter-organizational and intersectoral levels. Mobilization of actors from different sectors would facilitate the implementation of pertinent and opportune interventions.

Desires, Need, Perceptions, and Knowledge of Assisted Reproductive Technologies of HIV-Positive Women of Reproductive Age in Ontario, Canada

The purpose of this cross-sectional study is to assess the desire, need, perceptions, and knowledge of assisted reproductive technologies (ARTs) for women living with HIV (WLWHIV) and determine correlates of ART knowledge desire. WLWHIV of reproductive age were surveyed using the survey instrument "The HIV Pregnancy Planning Questionnaire" at HIV/AIDS service organizations across Ontario, Canada. Of our cohort of 500 WLWHIV, median age was 38, 88% were previously pregnant, 78% desired more information regarding ART, 59% were open to the idea of receiving ART, 39% felt they could access a sperm bank, and 17% had difficulties conceiving (self-reported). Age, African ethnicity, and residence in an urban center were correlated with desire for more ART information. Of participants, 50% wanted to speak to an obstetrician/gynecologist regarding pregnancy planning, and 74% regarded physicians as a main source of fertility service information. While the majority of participants in our cohort desire access to ART information, most do not perceive these services as readily accessible. Healthcare practitioners were viewed as main sources of information regarding fertility services and need to provide accurate information regarding access. Fertility service professionals need to be aware of the increasing demand for ART among WLWHIV.

Religion and HIV diagnosis among Africans living in London

OBJECTIVES

The aim of the paper was to describe the association of religion with HIV outcomes in newly diagnosed Africans living in London.

METHODS

A survey of newly diagnosed HIV-positive Africans attending 15 HIV treatment centres across London was carried out between April 2004 and February 2006. Confidential self-completed questionnaires were used, linked to clinical records. Bivariate analyses were conducted to ascertain whether religious beliefs were associated with late diagnosis, antiretroviral therapy, and immunological and virological outcome 6 months post diagnosis.

RESULTS

A total of 246 Black Africans were eligible and included in the analysis: 62.6% were women, and the median age was 34 years. The median CD4 count at diagnosis was 194 cells/μL (range 0-1334 cells/μL) and 75.6% presented late, as defined as a CD4 count < 350 cells/μL. Most participants were religious: non-Roman Catholic Christians (55.7%), Roman Catholics (35.2%) and Muslims (6.1%). Only 1.2% stated that they did not have a religion. Participants who attended religious services at least monthly were more likely to believe that 'faith alone can cure HIV' than those who attended less frequently (37.7% vs. 15.0%; P = 0.002). A small proportion (5.2%) believed that taking antiretroviral therapy implied a lack of faith in God. Bivariate analysis found no relationship between religiousness (as measured using frequency of attendance at religious services and religious attitudes or beliefs) and late diagnosis, changes in CD4 count/viral load 6 months post diagnosis, or initiation of antiretroviral therapy.

CONCLUSIONS

Strong religious beliefs about faith and healing are unlikely to act as a barrier to accessing HIV testing or antiretroviral treatment for Black Africans living in London.

'Dying from' to 'living with': framing institutions and the coping processes of African American women living with HIV/AIDS

How do HIV-positive individuals transition from believing and behaving as though they have a 'death sentence' to interpreting and coping with HIV as a chronic but manageable illness? Using interview data collected from 30 HIV-positive African American women beginning in 2005, we reveal how and why interactions with non-profit and government institutions help to explain variation between those who thrive and those who do not following an HIV diagnosis. We argue that 'framing institutions' shape the form and tenor of coping trajectories by offering initial information about one's HIV status, a conceptual framework for understanding what it means to have HIV, language to talk about one's condition, and resources to begin restructuring one's life in the wake of a diagnosis. Ultimately, we highlight how a diverse array of non-profit and government institutions not only play a critical part in helping women cope with HIV but also renegotiate their self-conceptions as black women in the wake of receiving another stigmatizing social marker. In short, organizational ties shape women's movement from beliefs and behaviors that suggest that they are 'dying from' this disease to attitudes and actions consistent with the notion that they can 'live with' HIV.

The use of focus groups to investigate sensitive topics: an example taken from research on adolescent girls' perceptions about sexual risks

The methodology of focus groups has been increasingly employed in the context of research in the social sciences, particularly in health-related inquiries. Considerations about the sensitive aspects of such research are not, however, very often seen in research reports or discussion on ways of conducting sensitive research. The scope of this paper is to share an experience of conducting focus group research on sensitive topics, such as AIDS, risk and sexual issues, highlighting some methodological issues. More specifically, it suggests ways of working with teenage girls in focus groups about sensitive topics. The advantages of the use of focus groups to explore views on HIV/AIDS and other sexual risks are also discussed. Socio-cultural approaches to risk and feminist thinking permeate the main arguments.

'The old-fashioned way': conception and sex in serodiscordant relationships after ART

This paper explores heterosexual women's accounts of conception and sex within serodiscordant relationships in the period after the advent of Anti-Retroviral Treatment in Australia. It utilises Goffman's theory of stigma and narrative identity theory as a framework for analysis. Six women had planned and conceived pregnancies, four had an unexpected pregnancy and one was attempting to conceive. Accounts of conception usually consisted of a story that involved unprotected sex, once, for the purpose of conceiving. This included what they perceived to be an acceptable risk; one they were willing to take for the desired outcome. Two women gave accounts of artificial insemination. The conception story was usually constructed for the benefit of family and friends aware of the women's status thereby reinforcing the woman's identity as responsible and moral. However, most women revealed their partner did not like condoms and used them sporadically or not at all, directly contradicting the 'conception story'. To justify their actions as informed and responsible, women constructed accounts around low viral load and female-to-male transmission. But a consequence of limited or no condom use was that some women reported worrying about ensuing stigma from their partner's and their families if their partner did seroconvert.

Love and HIV serodiscordance in gay men's accounts of life with their regular partners

This paper examines discourse on serodiscordant relationships in interviews with 16 HIV-positive and 3 HIV-negative gay men living in Scotland. Drawing on critiques concerning love, reason and HIV serostatus normativity, this paper supplies a much-needed insight into how gay men in serodiscordant relationships negotiate HIV prevention. Among other matters, some HIV-negative men were said to knowingly request risky sex with their HIV-positive partners as an expression of love. In some situations, the person without HIV claimed a normative serostatus that implied they could 'invest' more in the relationship by offering to have sexual intercourse that may expose them to HIV. Such dynamics expressed devotion on the part of the HIV-negative man, but implied obligation for the HIV-positive man. Based on these and other perspectives we argue for closer attention to gay men's subjectivity in the present circumstances of proliferating biomedical forms of HIV prevention; more thoroughly reflexive public health engagements with gay men's sexual cultures; and a research agenda for gay men that challenges HIV-serostatus normativity.

Exploring positive adjustment in HIV positive African women living in the UK

Research into living with HIV/AIDS has to date mainly focused on quality of life and there is little on the adjustment process for this group. The numbers of African women living with HIV/AIDS in the UK is growing and yet little is known about the adjustment experience for these women. This study explored aspects of positive adjustment to living with HIV/AIDS among a sample of African women living in London, UK. Transcripts of semi-structured interviews with 12 women were analysed using interpretative phenomenological analysis (IPA). Two superordinate themes emerged inductively from the data: positive changes in coping (subthemes: positive interpretation of their situation and positive behavioural changes) and positive growth since the HIV diagnosis (subthemes: changes in the value of life and, changes in goals and opportunities). While these women acknowledged the negative impact of living with HIV/AIDS, all participants mentioned changes in health behaviours to help regain mastery of their lives and comparing with others better-off and worse-off was used to enhance self-esteem and view their situation positively. The data show evidence for Taylor's Cognitive Adaptation Theory.

'Experts', 'partners' and 'fools': exploring agency in HIV treatment seeking among African migrants in London

In an attempt to promote patient agency and foster more egalitarian relationships between patients and doctors, discourse concerning health and wellbeing in the UK has increasingly centred around the notion of informed and 'expert' patients who are able to effectively input into the direction and management of their own health care and treatment. While the relationship between a patient and their doctor can play a vital role in influencing the treatment decisions and health-related outcomes of people living with long term illness, little is known about the ways in which people living with HIV actually perceive their relationship with their doctors, nor the implications this may have for the types of treatment they may seek to use and the related information that they share. Drawing on 11 focus group discussions and 20 repeat interviews undertaken in 2008-2009 with HIV-positive adult migrants from Zambia, Zimbabwe and South Africa living in the UK, this paper argues that patient-doctor relationships can be heavily influenced by the perceived legitimacy of different forms of medical knowledge and treatments and by culturally influenced ideas regarding health, wellbeing and agency. Despite a desire amongst some migrants to use 'traditional' medicines from southern Africa as well as other non-biomedical treatments and therapies, the research found that the perceived lack of legitimacy associated with these treatments in the UK rendered their use a largely clandestine activity. At the same time, many patients made clear distinctions concerning issues affecting their immediate health and factors influencing their more general wellbeing, which in turn, impacted upon the information that they chose to share with, or conceal from, their doctors. Such findings challenge assumptions underpinning policy promoting patient agency and have significant and, in cases, potentially adverse implications for the safety and effective administration and management of HIV treatments in African migrant populations and possibly more generally.

Interviewing Sub-Saharan migrants in Switzerland about HIV/AIDS: critical reflections on the interview process

Although research underpinnings for the interview process are often discussed in the scholarly community, reports of explicit experiences about this step are often insufficient or lacking in research publications on migrant health and in the context of HIV/AIDS. The authors highlight the challenges they encountered in conducting qualitative interviews in a multilingual, transcultural setting with Sub-Saharan migrants on HIV prevention and care. The authors discuss challenges and solutions during the conduct of interviews. They particularly highlight strategies on interview conduct, participant focus, and interviewer's behavior, which supported good quality in their research interviews. The main aim of the article is to critically reflect experiences and to suggest successful methods during interview phases with regard to the migrant setting and the sensitivity of the research topic.

Fertility desires and intentions of HIV-positive women of reproductive age in Ontario, Canada: a cross-sectional study

BACKGROUND

Improvements in life expectancy and quality of life for HIV-positive women coupled with reduced vertical transmission will likely lead numerous HIV-positive women to consider becoming pregnant. In order to clarify the demand, and aid with appropriate health services planning for this population, our study aims to assess the fertility desires and intentions of HIV-positive women of reproductive age living in Ontario, Canada.

METHODOLOGY/PRINCIPAL FINDINGS

A cross-sectional study with recruitment stratified to match the geographic distribution of HIV-positive women of reproductive age (18-52) living in Ontario was carried out. Women were recruited from 38 sites between October 2007 and April 2009 and invited to complete a 189-item self-administered survey entitled "The HIV Pregnancy Planning Questionnaire" designed to assess fertility desires, intentions and actions. Logistic regression models were fit to calculate unadjusted and adjusted odds ratios of significant predictors of fertility intentions. The median age of the 490 participating HIV-positive women was 38 (IQR, 32-43) and 61%, 52%, 47% and 74% were born outside of Canada, living in Toronto, of African ethnicity and currently on antiretroviral therapy, respectively. Of total respondents, 69% (95% CI, 64%-73%) desired to give birth and 57% (95% CI, 53%-62%) intended to give birth in the future. In the multivariable model, the significant predictors of fertility intentions were: younger age (age<40) (p<0.0001), African ethnicity (p<0.0001), living in Toronto (p = 0.002), and a lower number of lifetime births (p = 0.02).

CONCLUSIONS/SIGNIFICANCE

The proportions of HIV-positive women of reproductive age living in Ontario desiring and intending pregnancy were higher than reported in earlier North American studies. Proportions were more similar to those reported from African populations. Healthcare providers and policy makers need to consider increasing services and support for pregnancy planning for HIV-positive women. This may be particularly significant in jurisdictions with high levels of African immigration.

Coping with HIV: Caribbean people in the United Kingdom

Although Caribbean people in the United Kingdom are increasingly being affected by HIV/AIDS, there has been no examination of how they are coping with the illness. We investigate the coping strategies of HIV-positive Caribbean people using in-depth interviews with a purposively selected group of 25 residents of South London. The main coping strategies were more cognitive than behavioral: restricted disclosure, submersion, faith, and positive reappraisal. These strategies were intertwined in complex ways, and most were rooted in contextual factors, particularly cultural ones. Themes of loss, silence, and reinvention suffused respondents' narratives. Interventions should consider the high degree of stigmatization of HIV/AIDS in the Caribbean community, reluctance to disclose, the likelihood of an initial severe reaction to diagnosis, and external stressors. HIV-positive Caribbean people who are coping well could serve as mentors and role models for poor copers and newly diagnosed patients; establishing Caribbean-specific support groups might also assist coping.

Fertility intentions and reproductive health care needs of people living with HIV in Cape Town, South Africa: implications for integrating reproductive health and HIV care services

Tailoring sexual and reproductive health services to meet the needs of people living with the human immuno-deficiency virus (HIV) is a growing concern but there are few insights into these issues where HIV is most prevalent. This cross-sectional study investigated the fertility intentions and associated health care needs of 459 women and men, not sampled as intimate partners of each other, living with HIV in Cape Town, South Africa. An almost equal proportion of women (55%) and men (43%) living with HIV, reported not intending to have children as were open to the possibility of having children (45 and 57%, respectively). Overall, greater intentions to have children were associated with being male, having fewer children, living in an informal settlement and use of antiretroviral therapy. There were important gender differences in the determinants of future childbearing intentions, with being on HAART strongly associated with women's fertility intentions. Gender differences were also apparent in participants' key reasons for wanting children. A minority of participants had discussed their reproductive intentions and related issues with HIV health care providers. There is an urgent need for intervention models to integrate HIV care with sexual and reproduction health counseling and services that account for the diverse reproductive needs of these populations.

Coded talk, scripted omissions: the micropolitics of AIDS talk in an affected community in South Africa

In this ethnographic article, we explore the character of local discourse about AIDS in an affected township community in South Africa, describing the "indirection" that characterized communication about suspected cases of AIDS. Through a case study of one affected family, the article first explores the diverse ways in which people came to "know" that specific cases of illness were AIDS related, and how this "knowledge" was communicated. We consider why communication was indirect and coded, arguing that this reflected nota "denial" of its presence in this community but, rather, a complex group of overlapping concerns far from unique to AIDS: first, a normative injunction on naming potentially fatal conditions; second, an interest in pursuing different therapeutic options and the need to maintain hope of recovery; and third, a wish to avoid the "disrespect" entailed in referring directly to the nature of the problem in a context where, discursively, stigma was still present. The coded and indirect character of HIV/AIDS-related talk underlines the importance of ethnographic inquiry in understanding community responses to this epidemic, demonstrating that the subtleties entailed by verbal silence and elision should not be interpreted naively as collective "denial" but rather be grounded within existing patterns of responses to dangerous sickness.

Challenges in researching life with HIV/AIDS: an intersectional analysis of black African migrants in London

Most social science research on HIV has focused on prevention. The arrival of new therapies generated more studies on life with HIV. However most have been carried out in developed world contexts. Much less is known about the vast majority of those living with HIV and dying from AIDS. If this gap is to be filled, more qualitative research will be needed on affected individuals in the developing world and also among migrants who have left developing countries to live in the diaspora. It will also be essential to explore the lives of individuals from the same communities who may experience HIV in very different ways as a result of their gender and/or sexuality. This paper presents findings from three studies of Black African migrants living with HIV in London. It uses an intersectional approach to examine the similarities and the differences between the experiences of heterosexual women, heterosexual men and gay and/or bisexual men. The article highlights the importance of research of this kind both for providing the evidence base for context-specific policy development and also for making better conceptual and theoretical sense of the impact of HIV on individuals and their lives.

Families, children, migration and AIDS

Migration is very often a family affair, and often involves children, directly or indirectly. It may give rise to better quality of life for an entire family, or to bitter disappointment, and may also increase vulnerability to HIV and AIDS. This review, carried out for the Joint Learning Initiative on Children and AIDS, links the literature on "migration", on "HIV and AIDS" and on "families". Three themes are sketched: (1) As both HIV prevalence and circular migration increase, former migrant workers affected by AIDS may return to their families for care and support, especially at the end of life, often under crisis conditions. Families thus lose promising members, as well as sources of support. However, very little is known about the children of such migrants. (2) Following patterns of migration established for far different reasons, children may have to relocate to different places, sometimes over long distances, if their AIDS-affected parents can no longer care for them. They face the same adaptation challenges as other children who move, but complicated by loss of parent(s), AIDS stigma, and often poverty. (3) The issue of migrant families living with HIV has been studied to some extent, but mainly in developed countries with a long history of migration, and with little attention paid to the children in such families. Difficulties include involuntary separation from family members, isolation and lack of support, disclosure and planning for children's care should the parent(s) die and differences in treatment access within the same family. Numerous research and policy gaps are defined regarding the three themes, and a call is made for thinking about migration, families and AIDS to go beyond description to include resilience theory, and to go beyond prevention to include care.

Use of traditional complementary and alternative medicine for HIV patients in KwaZulu-Natal, South Africa

Background

Traditional medicine use has been reported is common among individuals with moderate and advanced HIV disease. The aim of this cross-sectional study was to assess the use of Traditional Complementary and Alternative Medicine (TCAM) for HIV patients prior to initiating antiretroviral therapy in three public hospitals in KwaZulu-Natal, South Africa.

Methods

Using systematic sampling, 618 HIV-positive patients were selected from outpatient departments from three hospitals and interviewed with a questionnaire.

Results

TCAM was commonly used for HIV in the past six months by study participants (317, 51.3%) and herbal therapies alone (183, 29.6%). The use of micronutrients (42.9%) was excluded from TCAM since mostly vitamins were provided by the health facility. Herbal therapies were the most expensive, costing on average 128 Rand (US$16) per patient per month. Most participants (90%) indicated that their health care provider was not aware that they were taking herbal therapies for HIV (90%). Herbal therapies were mainly used for pain relief (87.1%) and spiritual practices or prayer for stress relief (77.6%). Multivariate logistic regression with use of herbs for HIV as the dependent variable identified being on a disability grant and fewer clinic visits to be associated with use of herbs, and TCAM use for HIV identified being on a disability grant, number of HIV symptoms and family members not contributing to main source of household income to be associated with TCAM use.

Conclusion

Traditional herbal therapies and TCAM are commonly used by HIV treatment naïve outpatients of public health facilities in South Africa. Health care providers should routinely screen patients on TCAM use when initiating ART and also during follow-up and monitoring keeping in mind that these patients may not fully disclose other therapies.

Infertility Treatment for HIV-Positive Women

Thanks to antiretroviral combination therapy, HIV-infected individuals live longer, healthier lives and may wish to have children. Women with HIV can attempt to conceive naturally or through simple self-insemination to minimize the risk of horizontal HIV transmission. Assisted reproduction technology is necessary in couples with infertility, which can either be independent of HIV infection and its treatment or be associated with it. This article summarizes the latest evidence regarding the desire for a child in HIV-positive women and how HIV infection and its treatment may impact female fertility. Current data regarding access to and outcomes of assisted conception programs in HIV-positive women wishing to conceive in both high- and low-income countries is also reviewed.