HIV status disclosure to families for social support in South Africa (NIMH Project Accept/HPTN 043)

Disclosure Events and Psychosocial Well-Being Among Young South African Adults Living with HIV

BACKGROUND

Poor psychological well-being is both prevalent among South Africans living with HIV and has been associated with poor HIV clinical outcomes. However, the relationship between disclosure and psychological well-being remains unclear. This analysis sought to examine the relationship between two disclosure-related variables, disclosure status and reaction received, and psychosocial well-being among a sample of young adults living with HIV (YALWH) in urban South Africa.

METHOD

This was a secondary analysis using observational data from Standing Tall, a randomized controlled trial that recruited 100 participants ages 18-24 who tested positive for HIV after initially presenting to two well-established mobile clinics for HIV testing. Interviews investigating primary and secondary outcomes of interest were done at baseline and 6 months following recruitment.

RESULTS

About half (51%) of participants disclosed their HIV status within 6 months after recruitment. Simple linear regression analyses revealed that disclosure of HIV status within 6 months after study enrollment predicted significantly lower levels of disclosure concerns and internalized stigma (p < 0.05). Reactions to disclosure were not significantly associated with any of the measures of psychosocial well-being considered in this analysis (p > 0.05).

CONCLUSION

The results suggest that the act of disclosure among newly diagnosed YALWH may be associated with reductions in internalized stigma. In addition, the finding that the act of disclosure may be a more important determinant of psychosocial well-being than the reaction to disclosure has important implications for interventions designed to promote disclosure and psychosocial well-being in YALWH.

Social networks and HIV treatment adherence among people with HIV initiating treatment in rural Uganda and peri-urban South Africa

Timely initiation of and adherence to antiretroviral therapy (ART) is critical for improving HIV outcomes and reducing HIV transmissibility. Social networks, or the social relationships individuals have with each other, have been linked with positive health outcomes, but less is known about the extent to which social network composition and structure are associated with improved ART adherence among people living with HIV (PLWH). We conducted an ego-centric network study among 828 previously ART-naïve PLWH presenting for ART initiation at 11 clinics in Mbarara, Uganda (rural population) and Gugulethu, South Africa (peri-urban population). We collected social network data using name generator and name interpreter questions. ART adherence was monitored over 12 months using wireless monitors (Wisepill). Our primary outcome of interest was ART adherence during the 12-month follow-up period. We used generalized linear models to estimate the associations between network measures and ART adherence. PLWH at the Uganda site (compared with the South Africa site) were less isolated, had larger social networks, and had more social ties providing sufficient social support; they were also more likely to bridge different social groups whereby not all social ties were connected to each other. In Uganda, social isolation was associated with a 5.5 percentage point reduction in ART adherence (95% confidence interval [CI] -9.95 to -1.13; p = 0.014), while having more same gender social ties was associated with higher ART adherence (b = 0.13, 95% CI 0.02-0.25, p = 0.025). In South Africa, there was no association between social isolation and ART adherence, and having more friendship ties (vs. family ties) was associated with lower ART adherence (b = -2.20, 95% CI -3.56 to -0.84; p = 0.002). Identifying and supporting PLWH who are isolated may facilitate optimal adherence, but understanding how networks differentially affect ART adherence by country context is important.

Both/And: Mixed methods analysis of network composition, communication patterns, and socio-economic support within social networks of transgender women involved in sex work in Lima, Peru

INTRODUCTION

Social networks contribute to normative reinforcement of HIV prevention strategies, knowledge sharing, and social capital, but little research has characterized the social networks of transgender women (TW) in Latin America. We conducted a mixed methods analysis of three network clusters of TW in Lima, Peru, to evaluate network composition, types of support exchanged, and patterns of communication.

METHODS

We recruited TW residing in or affiliated with three "casas trans" (houses shared among TW) in Lima between April-May 2018. Eligible participants were 18 or older, self-reported HIV-negative, and reported recent intercourse with a cis-male partner. Participants completed demographic questionnaires, social network interviews, and semi-structured interviews to assess egocentric network structures, support exchanged, and communication patterns. Quantitative and qualitative data were analyzed using Stata v14.1 and Atlas.ti, respectively.

RESULTS

Of 20 TW, median age was 26 years and 100% reported involvement in commercial sex work. Respondents identified 161 individuals they interacted with in the past month (alters), of whom 33% were TW and 52% family members. 70% of respondents reported receiving emotional support from family, while 30% received financial support and instrumental support from family. Of the 13 (65%) respondents who nominated someone as a source of HIV prevention support (HPS), the majority (69%) nominated other TW. In a GEE regression analysis adjusted for respondent education and region of birth, being a family member was associated with lower likelihood of providing financial support (aOR 0.21, CI 0.08-0.54), instrumental support (aOR 0.16, CI 0.06-0.39), and HPS (aOR 0.18, CI 0.05-0.64). In qualitative interviews, most respondents identified a cis-female family member as their most trusted and closest network member, but other TW were more often considered sources of day-to-day support, including HPS.

CONCLUSION

TW have diverse social networks where other TW are key sources of knowledge sharing and support, and family members may also represent important and influential components. Within these complex networks, TW may selectively solicit and provide support from different network alters according to specific contexts and needs. HIV prevention messaging could consider incorporating network-based interventions with TW community input and outreach efforts for supportive family members.

Retention and Predictors of Attrition Among People Living With HIV on Antiretroviral Therapy in Guinea: A 13-Year Historical Cohort Study in Nine Large-Volume Sites

Objectives: The objective of this study was to estimate the retention rate of patients in an ART program and identify the predictors of attrition. Methods: This was a historical cohort study of HIV patients who started ART between September 2007 and April 2020, and were followed up on for at least 6 months in nine large-volume sites. Kaplan Meier techniques were used to estimate cumulative retention and attrition probabilities. Cox proportional hazards models were used to identify predictors of attrition. Results: The cumulative probability of retention at 12 and 24 months was 76.2% and 70.2%, respectively. The attrition rate after a median follow-up time of 3.1 years was 35.2%, or an incidence of 11.4 per 100 person-years. Having initiated ART between 2012 and 2015; unmarried status; having initiated ART with CD4 count <100 cells/μL; and having initiated ART at an advanced clinical stage were factors significantly associated with attrition. Conclusion: The retention rate in our study is much lower than the proposed national target (90%). Studies to understand the reasons for loss to follow-up are needed.

Incidence of HIV disclosure among HIV affected heterosexual partners using a community health worker led mechanism in rural Uganda; a quasi-experimental study

BACKGROUND

HIV disclosure is vital in HIV management. Community Health Workers (CHW) were reported to support partner disclosure among HIV affected heterosexual partners with disclosure difficulties. However, time to disclosure attributed to use of CHW led disclosure support mechanism was not documented. This study compared the incidence of sexual partner disclosure among adults living with HIV (ALHIV) with CHW support and those without in the greater Luwero region, Uganda.

METHODS

We conducted a quasi-experimental study with two arms allocated by geographically determined clusters and adjusted for between-group differences; among ALHIV in the greater Luwero region of Uganda who had never disclosed to their current primary sexual partners. We allocated study clusters to either a CHW-led intervention or control arm. In both arms, we consecutively recruited participants; those in the intervention arm received CHW disclosure support in addition to routine care. The overall follow-up was six months, and the primary outcome was disclosure to the partner. We used survival analysis with proportional hazard ratios to determine the time to partner disclosure in both arms.

RESULTS

A total of 245 participants were enrolled, and 230 (93.9%) completed the study; of these, 112 (48.7%) were in the intervention and 118 (51.3%) in the control arm. The mean age was 31 ± 8 years with a range of 18 to 55 years; the majority were females, 176 (76.5%). The cumulative incidence of disclosure was higher in the intervention arm, 8.76 [95% CI: 7.20-10.67] per 1,000 person-days versus 5.15 [95%CI: 4.85-6.48] per 1,000 person-days in the control arm, log-rank test, X2 = 12.93, P < 0.001. Male gender, aHR = 1.82, tertiary education, aHR = 1.51, and relationship duration of > six months, aHR = 1.19 predicted disclosure. Prior disclosure to a relative, aHR = 0.55, and having more than one sexual partner in the past three months, aHR = 0.74, predicted non-disclosure.

CONCLUSION

CHW-led support mechanism increased the rate of sexual partner disclosure among ALHIV with disclosure difficulties. Therefore, to achieve the global targets of ending HIV, near location CHW-led disclosure support mechanism may be used to hasten HIV disclosure in rural settings.

Sex specific differences in HIV status disclosure and care engagement among people living with HIV in rural communities in Kenya and Uganda

Non-disclosure of human immunodeficiency virus (HIV) status can hinder optimal health outcomes for people living with HIV (PLHIV). We sought to explore experiences with and correlates of disclosure among PLHIV participating in a study of population mobility. Survey data were collected from 1081 PLHIV from 2015-16 in 12 communities in Kenya and Uganda participating in a test-and-treat trial (SEARCH, NCT#01864603). Pooled and sex-stratified multiple logistic regression models examined associations of disclosure with risk behaviors controlling for covariates and community clustering. At baseline, 91.0% (n = 984) of PLHIV had disclosed their serostatus. Amongst those who had never disclosed, 31% feared abandonment (47.4% men vs. 15.0% women; p = 0.005). Non-disclosure was associated with no condom use in the past 6 months (aOR = 2.44; 95%CI, 1.40-4.25) and with lower odds of receiving care (aOR = 0.8; 95%CI, 0.04-0.17). Unmarried versus married men had higher odds of non- disclosure (aOR = 4.65, 95%CI, 1.32-16.35) and no condom use in the past 6 months (aOR = 4.80, 95%CI, 1.74-13.20), as well as lower odds of receiving HIV care (aOR = 0.15; 95%CI, 0.04-50 0.49). Unmarried versus married women had higher odds of non-disclosure (aOR = 3.14, 95%CI, 1.47-6.73) and lower odds of receiving HIV care if they had never disclosed (aOR = 0.05, 95%CI, 0.02-0.14). Findings highlight gender differences in barriers to HIV disclosure, use of condoms, and engagement in HIV care. Interventions focused on differing disclosure support needs for women and men are needed and may help facilitate better care engagement for men and women and improve condom use in men.

A qualitative analysis of family support for adolescent HIV care in South Africa

Compared to other age groups, South African adolescents living with HIV (ALWH) have the lowest rates of retention in HIV care and medication adherence. While previous research suggests that familial social support may improve treatment retention and adherence within this population, we know little about the influence of differential types of social support on HIV-related outcomes. Thus, the purpose of this study is to qualitatively characterize the influence of type of familial social support on treatment retention and adherence among ALWH. We interviewed adolescents living with perinatally-acquired HIV (n = 20), their caregivers (n = 19), and community stakeholders (n = 20) in Cape Town, South Africa. Data were coded using deductive and inductive approaches to content analysis. We identified four types of familial social support: instrumental, appraisal, emotional, and informational support. Families provided instrumental support through logistical assistance, including transportation to appointments and pill reminders. Families also provided both emotional support and appraisal support, encouraging ALWH to adhere to their medication regimens by reflecting upon its importance to their futures. For informational support, families often educated ALWH about their HIV status and strategies for disease self-management. In characterizing familial social support, our findings highlight potential targets of future interventions to improve HIV-related outcomes among ALWH.

Psychological Distress Increases 30-Fold Among People with HIV in the First Year on ART in Nigeria-a Call for Integrated Mental Health Services

BACKGROUND

Few studies have longitudinally assessed psychological distress among people with HIV (PWH) initiating ART in resource-limited settings.

METHOD

Baseline, 6-month, and 12-month psychological distress were measured in a Nigerian cohort newly initiating therapy; the relationship between baseline factors and psychological distress at 12 months was assessed; and the association between psychological distress at 12 months and care retention or immunologic failure was determined.

RESULTS

Among 563 patients, median age was 38 years (IQR: 33-46 years), 62% were female, and 51% were married. Psychological distress increased from 3% at baseline to 34% at 12 months. Age (aOR 1.28, 95% CI 1.06-1.56), female sex (aOR 2.89, 95% CI 1.93-4.33), lack of disclosure (aOR 4.32, 95% CI 2.48-7.51), and time on ART (6 months [aOR 6.91, 95% CI 3.14-15.18] and 12 months [aOR 32.63, 95% CI 16.54-64.36]) were associated with psychological distress while being married (OR 0.42, 95% CI 0.30-0.61) was associated with reduced odds. Tweve-month psychological distress was associated with increased risk of immunologic failure (aOR 2.22, 95% CI 1.31-3.82).

CONCLUSION

The risk of psychological distress increased 30-fold in the first year on therapy in PWH in Nigeria.

HIV Disclosure Among Sexually Infected People Living with HIV and AIDS in China: Prevalence, Influencing Factors, and Negative Outcomes

HIV disclosure is crucial for HIV prevention and control, but may also lead to discrimination, insult, and even violence against people living with HIV and AIDS (PLWHAs). In this study, we examined HIV disclosure, its influencing factors, and its association with intimate partner violence (IPV) among 1153 PLWHAs through the sexual route in Jinan, Shandong Province, China. Our results showed that 76.4% (881/1153) PLWHAs had disclosed someone about their HIV infection, the HIV disclosure rates among family members, friends, spouses, and current fixed partners of PLWHAs were 43.5% (501/1153), 47.9% (552/1153), 56.8% (129/227), and 43.2% (336/777), respectively. HIV disclosure was affected by socio-demographics, disease characteristics, and psycho-social factors and varied among family members, close friends, spouses, and current fixed sexual partners. Age ≤ 33 years (aOR 1.79, 95% CI 1.27-2.53), heterosexual infection route (aOR 1.52, 95% CI 1.06-2.17), HIV diagnosis time > 36 months (aOR 1.84, 95% CI 1.30-2.59), with other chronic diseases (aOR 1.87, 95% CI 1.34-2.61), lower self-stigma (aOR 4.03-4.36, 95% CI 1.98-8.74), higher social support (aOR 1.71-1.73, 95% CI 1.03-2.83), no depression (aOR 1.54, 95% CI 1.12-2.11), and no suicidal ideation (aOR 1.79, 95% CI 1.28-2.50) were all independently associated with increased likelihood of HIV disclosure. HIV disclosure was associated with an increased risk of IPV among current fixed sexual partners (aOR 1.87, 95% CI 1.38-2.54) and spouses (aOR 2.54, 95% CI 1.41-4.56). Our findings suggest that the HIV disclosure rate of PLWHAs is still low and is affected by multiple factors. There is an urgent need to design targeted and comprehensive interventions to improve HIV disclosure. IPV prevention should also be incorporated into the intervention system of HIV disclosure to ensure adequate and continuous support for PLWHAs.

Social Support for Improved ART Adherence and Retention in Care among Older People Living with HIV in Urban South Africa: A Complex Balance between Disclosure and Stigma

The number of older people living with HIV (OPLWH) (aged 50-plus) in South Africa is increasing as people age with HIV or are newly infected. OPLWH are potentially vulnerable because of the intersection of age-related and HIV stigmas, co-morbidities, and lack of social support. Evidence from younger populations suggests that social support can improve ART adherence and retention in care. Further, HIV status disclosure plays a role in mediating social support and may reduce stigma by facilitating access to social support. This paper draws on qualitative research with OPLWH to explore the complex associations between disclosure, social support, and HIV stigma among OPLWH in urban Western Cape. The findings demonstrate that OPLWH receive most of their support from their family and this support can facilitate adherence to ART and retention in care. However, social support is facilitated by participants' disclosure, thus, when perceived stigma limits disclosure, social support is less accessible. Gender, age, and pre-existing vulnerability also affect disclosure to and support from kin and community. Given that social support, particularly from family members, amplifies HIV care access and ART adherence, encouraging disclosure stimulating household HIV competency is likely to both address anticipated stigma and support improved OPLWH's health outcomes.

To disclose or not: experiences of HIV infected pregnant women in disclosing their HIV status to their male sexual partners in Blantyre, Malawi

Background

HIV status disclosure is one of the pillars of success of the elimination of Mother to Child Transmission of HIV (eMTCT) program. However, there are challenges associated with it that limit full disclosure. Literature shows that for pregnant women in developing countries, who have been diagnosed with HIV, 16% to 86% disclose their status to their sexual partners. This study explored the experiences of newly diagnosed HIV-infected antenatal women in disclosing their HIV status to their male sexual partners in Blantyre, Malawi.

Methods

This was a qualitative explanatory multiple case study that was conducted from 2018 to 2019 using in-depth interviews and diaries as data collection tools. We recruited seven newly diagnosed HIV pregnant women who had not disclosed their status to their male sexual partners and were initiated on Option B + strategy of the eMTCT of HIV at Limbe Health Centre. The investigator had 3 contacts with each participant from which data was gathered except for one participant who got lost to follow-up. This study employed content analysis and used a within-case and across-case analysis.

Results

Women either use facilitated mutual disclosure process or disclosed directly to their male sexual partners. Women were motivated to disclose because they wanted an HIV-free baby, to know the partners' status, and to resolve the gap on how they got infected with HIV. The disclosure process faced challenges such as uncertainty about a partner’s reaction after disclosure, fear of relationship dissolution, and the soberness of the partner. Privacy was an important consideration during the process of disclosure. Following disclosure, male sexual partners either accepted the status immediately after disclosure or initially denied but later accepted.

Conclusion

This study has shown that newly diagnosed HIV pregnant women accessing eMTCT services have a plan of either to disclose or conceal their HIV status from their male sexual partner and this decision is affected by the nature of relationship that exist between them and their partner. Factors relating to the unborn baby, the relationship as well as to know partners status motivate women to either disclose or conceal.

Loss to follow-up of patients in HIV care in Burundi: A retrospective cohort study

OBJECTIVE

The objective was to assess the loss to follow-up (LTFU) rates and associated factors amongst patients in HIV care in Burundi.

METHODS

We conducted a retrospective cohort study in HIV-positive patients aged ≥15 years who started antiretroviral therapy (ART) between January 2015 and July 2020, with 31 December 2020 as the end point. The outcome of LTFU was defined as failure of a patient to report for drug refill within 90 days from the last appointment. Study data were extracted from the national AIDS Info database. The LTFU proportion was determined using the Kaplan-Meier method with the log-rank test, whereas LTFU risk factors were explored using the Cox regression model.

RESULTS

A total of 29,829 patients on ART were included in the analysis. Cumulative incidence of LTFU was 2.3% at 12 months, 6.5% at 24 months, 12.7% at 36 months, 19.0% at 48 months, 24.1% at 60 months and 25.3% at 72 months. The overall LTFU incidence rate was 11.2 per 100 person-years of observation. The risk of LTFU was higher amongst patients who started ART after 2016 (adjusted hazard ratio [aHR] 1.75, 95% confidence interval [CI] 1.65-1.85) or within 7 days after diagnosis (aHR 1.27, 95% CI 1.21-1.35).

CONCLUSION

Our findings demonstrate the relatively high incidence of LTFU in the Burundi HIV programme. Interventions targeting patients with risk factors for LTFU are particularly necessary.

Association between Internalized Stigma and Depression among People Living with HIV in Thailand

Internalized stigma and depression are among the most common mental health problems in people living with HIV (PLHIV). This study aimed to examine the association between depression and overall internalized stigma, as well as different aspects of internalized stigma in PLHIV. The study included 400 PLHIV receiving care in Bangkok and Chiang Mai, Thailand. Data were analyzed using descriptive statistics, Mann-Whitney U test, and Spearman correlation coefficients. The results indicated the PLHIV with mild depression had lower median scores for the social relationship internalized stigma subscale than PLHIV with major depressive disorder (p = 0.009). Total HIV internalized stigma scores were significantly correlated with PHQ-9 scores in the mild depression group (r = 0.327, p = 0.004). Depression and internalized stigma were prevalent and associated, especially in the area of social relationships. Health personnel should be aware of possible depression in PLHIV who have internalized stigma. Intervention to promote understanding and social support for PLHIV is warranted.

HIV serostatus disclosure to sexual partner: a survey among women in Tehran, Iran

BACKGROUND

Disclosure of HIV-positive status in women is associated with many factors. Consequently, status disclosure remains a challenge for Iranian women living with HIV. This study aimed to assess the prevalence, related factors, and reflections of HIV-positive status disclosure to a sexual partner(s) among Iranian women living with HIV.

METHODS

A cross-sectional study was conducted on 170 HIV-seropositive women. Participants were selected from patients registered in the largest HIV clinic and HIV-positive club of Iran. The "HIV disclosure" questionnaire had 38-items and all the interviews were administered by the researcher. Data were analyzed using SPSS version 21.0 software. We used a logistic regression method to calculate the crude odds ratio (COR) and the adjusted odds ratio (AOR) for self-disclosure as the independent predictor variable and the dependent variable, respectively.

RESULTS

One hundred and seventy HIV-positive women were enrolled. Most of them had disclosed their HIV status to at least one person (94.1%) and their sexual partners (86.5%). In the univariate analysis, being married (COR = 18.66, 95% CI 5.63-61.87), living with a sexual partner (COR = 4.72, 95% CI 1.92-11.62), being aware of sexual partners' HIV status (COR = 6.20, 95% CI 1.79-21.49), and gaining the support of sexual partner (COR = 9.08, 95% CI 3.48-23.64) were associated with higher odds of HIV status disclosure. In the multivariate analysis, being aware of sexual partners' HIV status, and gaining the support of sexual partners remained associated with HIV status disclosure. Most women reported a positive reflection from their sexual partners after disclosure, however, negative reflections from society were more common compared to sexual partners and family members.

CONCLUSION

This study shows high overall HIV disclosure proportions. It should be noted that a large number of women were infected by their sexual partners, especially by their spouses. The high rate of transmission in married people indicates an urgent need for more emphasis on appropriate prevention behaviors by infected partners.

HIV related stigma associated with social support, alcohol use disorders, depression, anxiety, and suicidal ideation among people living with HIV: a systematic review and meta-analysis

Background

Stigma is a social phenomenon known to have a negative impact on the lives of people living with HIV (PLWH). However, defining HIV-related stigma (HRS) is difficult because of the intersection it has with structural inequalities, and cultural differences, discrimination by health care providers that measure stigma among PLWH. HIV/AIDS has been characterized as a traumatic experience and PLWH may experience stigma which can cause negative mental health disorders and experiences, including emotional distress, shame, depression, anxiety, suicidal ideation. A systematic review of the evidence on the mental disorders of PLWH is currently lacking. This study aimed to analyze the association between HRS and social support, alcohol use disorders and mental health disorders and experiences (depression, anxiety, and suicidal ideation) among PLWH.

Methods

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) this study searched PubMed, Scopus, Web of sciences, PsycInfo, SciELO and Cochrane library electronic databases to identify publications between January 1992 and August 2020 that discussed social support, alcohol use disorders, mental health disorders and experiences (i.e., depression and anxiety and suicidal ideation) associated with HRS. Pooled Odds Ratios (ORs) were utilized at a 95% confidence level, and as sampling methods differed between articles pooled estimates used a random effects model.

Results

Twenty-two studies with 9548 participants met the eligibility criteria. No association was observed between HRS and alcohol use disorders. PLWH who had higher levels of social supports were less likely to report HRS. Participants who had been diagnosed with anxiety were 1.89 times more likely to report HRS, while those diagnosed with depression were 1.61 times more. Respondents who reported suicidal ideation also were 1.83 times more likely to report HRS.

Conclusions

This meta-analysis supports that HRS has a detrimental association with anxiety, depression and suicidal ideation, but social support protects again HRS in PLWH. Applying interventions which focus on the mental health disorders of PLWH may decrease HRS. Provision of social support by practitioners, combined with mental health treatment and assessments, and designing methods to identify stigma at different stages of illness are warranted.

Depressive Symptoms, Gender, Disclosure, and HIV Care Stage Among People Living with HIV in Cameroon

Depression is associated with suboptimal HIV care outcomes. Little is known about the extent to which the prevalence of depressive symptoms varies across the HIV care continuum. Also, the relationship among gender, HIV disclosure, HIV care stage, and depressive symptoms in PLWH remains poorly understood. We analyzed cross-sectional data from 12,507 PLWH at enrollment in International epidemiology Databases to Evaluate AIDS (IeDEA) Cameroon between 2016 and 2020. Recent depressive symptoms were assessed using the Patient Health Questionnaire-2 (PHQ-2). A score of three or greater on the PHQ-2 was considered indicative of likely major depressive disorder. We estimated the prevalence of depressive symptoms across three stages of HIV care: those not yet on antiretroviral therapy (ART), recent ART initiators (ART initiation ≤ 30 days prior), and ART users (ART initiation > 30 days prior). Adjusted prevalence differences (aPD) of depressive symptoms were estimated comparing recent ART initiators and ART users. Disclosure and gender were examined as effect measure modifiers of the relationship between HIV care stage and depressive symptoms. The prevalence of depressive symptoms was 11.9%, 22.0%, and 8.7% among PLWH not yet on ART, recent ART initiators, and ART users, respectively. ART users had significantly lower prevalence of depressive symptoms compared to recent ART initiators (aPD - 0.09 [95% CI - 0.11, - 0.08]). Neither gender nor HIV disclosure modified the effect measure of the relationship between HIV care stage and depressive symptoms. Depressive symptoms were commonly reported among this group of PLWH and were associated with recent ART initiation. Integration of screening and treatment of depression into HIV care should be prioritized and may be particularly relevant for PLWH initiating ART.

Associations between antiretroviral therapy-related experiences and mental health status among people living with HIV in China: a prospective observational cohort study

BACKGROUND

Mental health problems (e.g., depression and anxiety) are among the most commonly reported comorbidities of HIV. Antiretroviral therapy (ART) coverage has increased sharply. The purposes of this prospective cohort study were to investigate the ART-related experiences and whether they were associated with mental health problems among a sample of people living with HIV undergoing ART in China.

METHODS

The participants were 400 people living with HIV who had started ART for the first time in Guangzhou city. They were followed-up 1-year after ART initiation. Probable depression and moderate/severe anxiety were measured at baseline and Month 12, while experiences related to ART (e.g., side effects and regained self-confidence) were measured at Month 6. Univariate and multivariate logistic regressions were used to explore the associations between baseline characteristics, ART-related experiences and mental health status.

RESULTS

Among the 300 participants (75.0%) who completed all three surveys, a significant decline in prevalence of probable depression (23.0% at baseline vs. 14.0% at Month 12, P = 0.002) and moderate/severe anxiety (14.7% at baseline vs. 8.7% at Month 12, P = 0.023) was observed during the follow-up period. After adjustment for mental health status and potential confounders at baseline, a number of ART-related experiences at Month 6 were associated with probable depression and/or moderate/severe anxiety measured at Month 12. Improved physical health, relationships with sexual partners, and self-confidence were associated with decreased mental health issues, while the side effects of ART, AIDS-related symptoms, and inconvenience in daily life due to ART use were associated with increased mental health issues.

CONCLUSIONS

ART-related experiences were associated with mental health problems, tailored mental health promotion interventions targeting these experiences are needed.

An HIV Narrative of Female Inmates With a Lifetime History of Mental Illness in Durban, South Africa

Introduction: South Africa (SA) has one of the highest prevalence rates of Human Immuno-deficiency Virus (HIV) globally, with women carrying a larger burden of the disease. Furthermore, female inmates have higher rates of HIV compared to their male counterparts, with an over-representation of mental illnesses among female inmates as well. Additionally, mental illnesses are highly prevalent in people living with HIV, with HIV and mental illness sharing a complex bidirectional relationship. This study, which forms part of a larger two-phased, mixed-methods study, describes the experiences of contracting and living with/being affected by HIV, among female inmates with a lifetime history of mental illness, in a South African setting. Method: This study was conducted at a correctional centre in Durban, KwaZulu-Natal, SA. Fourteen adult (18 years and older) female inmates, were purposively selected to participate in individual, in-depth semi-structured interviews. Participants had a lifetime history of mental illness, trauma and were either living with HIV, or affected by HIV. Women from diverse cultural backgrounds, who were fluent in English, were selected. This manuscript focuses on the description of the HIV component of the qualitative interviews only. Thematic analysis was used to analyse the data. Results: Themes related to contracting HIV included intimate partner betrayal, gender differences regarding sexual behaviour, fear associated with HIV and the importance of pre- and post-test HIV counselling. Themes related to living with/being affected by HIV included the challenges women experienced in their home community, which contrasted with their experience of living with HIV in the prison community, and the importance of accepting an HIV positive life. Conclusion: HIV is prevalent in the female inmate population at this correctional centre in SA. This study emphasises that whilst incarcerated, attempts should be made to educate, train, support and manage HIV in this population, thereby helping to curb the epidemic. Further research should aim at exploring such strategies. The study also underscores the importance of the continued need for HIV education in order to eradicate associated stigma and discrimination which are still prevalent in SA.

Perceived Stigma as a Contextual Barrier to Early Uptake of HIV Testing, Treatment Initiation, and Disclosure; the Case of Patients Admitted with AIDS-Related Illness in a Rural Hospital in South Africa

We explored the extent to which perceived HIV-related stigma influences the disclosure and concealment of HIV status to family among adult patients hospitalised for AIDS-related illness, and described reports of negative responses and enacted stigma following disclosure. We conducted interviews with a purposeful sample of 28 adult patients in a rural South African hospital. Data analysis was deductive and inductive and followed the thematic approach. We found evidence of delayed HIV diagnosis and initiation of treatment. There was delayed and selective disclosure as well as concealment of the HIV-positive status. The disclosure was delayed for months or even years. During that time, there was active concealment of the HIV status to avoid stigma from family, friends, and community. When disclosure occurred, there was selective disclosure to close family members who would keep the secret and respond favorably. Although the participants disclosed mostly to close family, some of their post-disclosure experiences included incidents of enacted stigma and discrimination. The fear of perceived stigma and self-stigma influenced the active concealment of their HIV status from others. Continuous concealment of one's HIV status and delayed disclosure limit the opportunities for support and care. There is a need to take into consideration the interaction between HIV-related stigma and disclosure to develop disclosure-counselling strategies in primary health care settings.

Using decision tree analysis to understand the influence of social networks on disclosure of HIV infection status

Disclosure of human immunodeficiency virus (HIV) infection status improves treatment adherence and HIV prevention. Social networks influence such disclosure by people living with HIV/AIDS (PLWH). This study aimed to investigate the disclosure status of Korean PLWH and determine the social network characteristics associated with disclosure. A cross-sectional study design was used, and 148 Korean PLWH answered self-report questionnaires that included items on the characteristics of social networks and disclosure. Logistic regression and decision tree analysis were performed. In total, 81 participants (54.7%) reported disclosing HIV status to the most important supporter. Five factors were found to influence disclosure: age, self-help group participation, living arrangement, social network relationship, and tie strength; three groups had higher percentages of nondisclosure. The findings suggest that healthcare practitioners should provide adequate counseling by considering the characteristics of social networks and disclosure status of PLWH. Researchers should identify high-risk populations using decision tree analysis.

Social Support, Food Insecurity, and HIV Stigma Among Men Living with HIV in Rural Southwestern Uganda: A Cross-Sectional Analysis

BACKGROUND

HIV stigma is one of the major barriers to HIV care due to the fear of disclosure and social discrimination. HIV stigma among men in sub-Saharan countries, including Uganda, has been linked to the fear about how HIV status might affect their status in society. HIV among men in sub-Saharan settings has been associated with feelings of shame, reduced self-worth, and self-blame for their HIV positive status. Information about HIV stigma and its associated factors among men living with HIV in rural Uganda is limited. This study assessed the burden of HIV stigma and its association with social support and food insecurity among men accessing HIV care at a rural health facility in southwestern Uganda.

METHODS

We conducted a clinic-based cross-sectional study and consecutively enrolled 252 adult men accessing HIV care at a rural health centre in southwestern Uganda. We collected information on sociodemographic information, HIV stigma, social support, and food insecurity. We fitted modified Poisson regression models to determine the associations between social support, food insecurity, and HIV stigma.

RESULTS

The mean HIV stigma score of the study participants was 70.08 (SD 19.34) and 75% reported food insecurity 5% of whom were severely food insecure. The risk of HIV stigma was lower among those aged 35 years and above (adjusted risk ratio [ARR]=0.89; 95% CI 0.83-0.96; P=0.003, those who had been on ART for more than 5 years (ARR=0.92; 95% CI=0.84-0.99; P=0.04), and those who had social support (ARR=0.99; 95% CI=0.98-0.99; P=<0.001). Food insecurity was associated with an increased risk of HIV stigma (ARR=1.07; 95% CI 1.00-1.15; P=0.03). Social support moderated the effect of food insecurity on HIV stigma (P=0.45).

CONCLUSION

Stigma is common among men living with HIV in rural Uganda and is significantly associated with food insecurity. Social support moderated the effect of severe food insecurity on HIV stigma among men living with HIV. Interventions to build social support systems and to economically empower men living with HIV should be incorporated into the mainstream HIV care clinics.

From "Secret" to "Sensitive Issue": Shifting Ideas About HIV Disclosure Among Middle-Aged and Older Rural South Africans in the Era of Antiretroviral Treatment

OBJECTIVE

As HIV shifts from "death sentence" to "chronic condition," disclosure of HIV status to intimate partners and family is a significant component of both prevention and treatment adherence. While disclosure is closely considered in many studies, few examine middle-aged and older persons' (age 40+) perspectives or practices. We trace older rural South Africans' views on HIV disclosure to their partners and family members in a high prevalence community over a period of extensive antiretroviral treatment (ART) rollout.

METHODS

Community focus group discussions (FGD) conducted in 2013 and 2018 show shifts in older persons' thinking about HIV disclosure.

FINDINGS

Our FGD participants saw fewer negative consequences of disclosure in 2018 than in 2013, and highlighted positive outcomes including building trust (partners) as well as greater support for medication collection and adherence (family).

DISCUSSION

Particularly as the epidemic ages in South Africa and globally, tracing changes in older persons' views on disclosure is an important step in developing messaging that could enhance treatment as prevention and ART adherence.

Disclosure experience among COVID-19-confirmed patients in China: A qualitative study

AIM

To understand COVID patients' experiences of and perspectives on disclosure of their illness and to explore and describe the factors affecting disclosure decisions among COVID patients in China.

BACKGROUND

Disease disclosure is a critical component of prevention and control of a virus outbreak, and this is especially true during the COVID-19 pandemic. Understanding COVID patients' experiences and perspectives on disclosure could play a vital role in COVID management.

DESIGN

A qualitative study.

METHODS

A semi-structured interview guide was used to conduct qualitative in-depth interviews from April to June 2020. All the interviews were audio-recorded and transcribed, and then, a thematic analysis was conducted. The Standards for Reporting Qualitative Research (SRQR) were applied to this study.

RESULTS

A total of 26 COVID-confirmed patients were recruited for the in-depth interviews. Four themes emerged from the thematic analysis on disclosure: persons disclosed to, reasons for disclosure, reasons for nondisclosure and impact of disclosure. The participants disclosed their COVID diagnosis to different groups, including family, close friends, community members and workplace contacts. The main reasons for disclosure included the following: government policy, social responsibility, gaining support and fear of being blamed for nondisclosure. However, some participants decided not to disclose to some groups for fear of facing stigma and discrimination or to protect family members from discrimination. Despite the potential benefits of obtaining support after disclosure, many participants did experience stigma and discrimination, privacy exposure, psychological distress and social isolation.

CONCLUSIONS

An individual's decision as to whether to disclose their COVID-positive status is affected by many factors. To prevent the spread of COVID-19 and reduce the potential risks of disclosure, such as discrimination and privacy exposure, a balanced intervention should be designed to protect COVID patients and to secure any contact tracing. Therefore, the chances of discrimination could be decreased and patients' confidentiality could be protected.

RELEVANCE TO CLINICAL PRACTICE

As the number of COVID patients increases, disclosure of an individual's infectious status is encouraged by health departments. Despite the potential benefits of disclosure, discrimination and privacy exposure should not be ignored. A disclosure protocol is necessary to ensure patients' privacy regarding their COVID status.

Lived Experiences of Adolescent Living with human immunodeficiency virus in Ghana: A Phenomenology Study

Aim and objectives

To explore the meaning of living with HIV positive in Ghanaian adolescents.

Design

Hermeneutic phenomenological approach developed by Van Manen methodology (1990).

Method

A purposive sampling of 12 adolescents living with HIV was recruited. Data were collected between September 2019-January 2020 using semi-structured interviews and analysed using thematic analysis.

Results

Two main themes emerged: Stigmatization and HIV disclosure and Living with a heavy burden. Seven subthemes were also found. Adolescents living with HIV in Ghana face discrimination, rejection and go through psychological distress such as suicidal thoughts, fear of death and hopelessness.

Conclusion

The problems faced by adolescents living with HIV are a result of the inherent beliefs of the Ghanaian society about HIV. Nurses working with ADLHIV should concentrate on identifying challenges and provide support and care, in addition to their treatment.

Effect of Disclosure on Receiving Spousal Support in Korean Immigrants With Type 2 Diabetes

PURPOSE

The purpose of this study was to investigate factors associated with receiving diabetes spousal support in a sample of Korean immigrants with type 2 diabetes (T2DM) and to test whether disclosure (culture-specific factor) is a significant predictor of spousal support receipt in this group.

METHODS

A cross-sectional survey was conducted with a convenience sample of 136 US community-dwelling Korean immigrants with T2DM ages 46 to 89 years old. Potential predictors were sociodemographic factors (age, gender, education, years in US), personal characteristics (quality of marriage and depression), diabetes severity (duration of diabetes, A1C, insulin use), diabetes self-management, diabetes worries/concerns (psychological factor), and disclosure of worries (cultural factor). The study used validated survey instruments including Diabetes Care Profile for spousal support received, Summary of Diabetes Self-Care Activities, Problem Area in Diabetes, and Diabetes Distress Disclosure Index. Descriptive statistics, correlations, and hierarchical multivariable linear regression models were conducted.

RESULTS

Six predictors (education level, years spent in the US, glucose control status, diabetes self-management level, diabetes worries/concerns, and disclosure of diabetes worries) were significantly related to receiving spousal support. At least some college education, less time in the US, better glucose control (lower A1C), poor self-management, more diabetes worries, and more disclosure of diabetes worries/distress were associated with receiving higher level of spousal support. Disclosure was the strongest predictor.

CONCLUSION

Receiving spousal support for diabetes self-management among Korean immigrants is influenced by 6 factors identified in this study. Disclosing diabetes worries (cultural factor) is most impactful.

'There are no more secrets': acceptability of a family-centered model of care for HIV positive children in Eswatini

BACKGROUND

HIV-positive children have lagged adults on retention in HIV care and viral suppression. To address this gap, Eswatini's Ministry of Health started a pilot family-centered HIV care model (FCCM) targeting HIV-positive children under 20 years old and their families.

METHODS

We conducted semi-structured in-depth interviews with 25 caregivers and 17 healthcare workers (HCWs) to assess acceptability of FCCM in four pilot FCCM health facilities in Hhohho region of Eswatini. Thematic analysis with inductive and deductive codes was used to identify salient themes.

RESULTS

Caregivers and HCWs reported FCCM benefits including strengthening the family bond, encouragement for family members to disclose their HIV status and supporting each other in taking antiretroviral drugs. Caregivers reported that they spent fewer days in clinic, experienced shorter waiting times, and received better counseling services in FCCM compared to the standard-of-care services. FCCM implementation challenges included difficulty for families to attend clinic visits together (e.g., due to scheduling conflicts with weekend Teen Support Club meetings and weekday FCCM appointments). Both HCWs and caregivers mentioned difficulty in sharing sensitive health information in the presence of other family members. HCWs also had challenges with supporting caregivers to disclose HIV status to children and managing the larger group during clinic visits.

CONCLUSIONS

FCCM for HIV-positive children was acceptable to both caregivers and HCWs, and they supported scaling-up FCCM implementation nationally. However, special considerations should be made to address the challenges experienced by participants in attending clinic visits together as a family in order to achieve the full benefits of FCCM for HIV positive children.

Complexities of HIV Disclosure in Patients Newly Entering HIV Care: A Qualitative Analysis

The role of HIV disclosure and its influence on engagement in HIV care after initial linkage to care is not well understood. We conducted 28 in-depth interviews with patients newly entering HIV care. Gaining access to social support was a key reason that many patients disclosed their HIV status. For some, HIV disclosure improved support networks related to engagement in care at the time of care entry, in the form of appointment reminders, emotional support, and confidence to disclose more widely. However, some participants cited anticipated stigma as a barrier to disclosure, as they feared rejection or further disclosure without their permission. Early access to social support and skill building related to stigma reduction and coping can be useful resources to help patients manage HIV, as they initiate care. In addition, incorporating support for smart disclosure decisions into interventions may improve access to social support, ultimately improving engagement in care.

Factors influencing sexually transmissible infection disclosure to male partners by HIV-positive pregnant women in Pretoria townships, South Africa: a qualitative study

Background Sexually transmissible infections (STI) may increase the risk of mother-to-child transmission (MTCT) of HIV. However, diagnostic testing and targeted treatment of STI (STI-TT) during pregnancy is not standard care in South Africa.

METHODS

A qualitative study was nested in a STI-TT intervention to investigate motivating and enabling factors associated with STI test results disclosure to sexual partners. A semi-structured interview protocol covered partner communication, HIV and STI disclosure, financial security and relationships dynamics. Interviews were conducted in participants' preferred language, audio-recorded, transcribed into English and analysed using a constant comparison approach. The study was conducted in two townships in Pretoria, South Africa.

RESULTS

Twenty-eight HIV-positive pregnant women were interviewed. Based on the interviews, two disclosure experiences for women were identified - those with vulnerable experiences and those with self-enabling experiences within their partnerships. Vulnerable women discussed intimate partner violence (IPV) and fear of relationship dissolution as factors influencing their test result disclosure. Self-enabled women discussed their ability to talk with their partners about STI and HIV infections and the influence of multiple concurrent partnerships in the acquisition of HIV/STIs. Both groups of women were concerned about men's health behaviours, and all cited the health and development of their unborn child as a key motivator for test result disclosure.

CONCLUSIONS

Improved counselling and support for pregnant women to disclose their STI test results to their partners may improve the impact of STI diagnostic testing during pregnancy by improving partner treatment uptake and thus reducing the risk of re-infection.

Support or control? Qualitative interviews with Zambian women on male partner involvement in HIV care during and after pregnancy

BACKGROUND

Efforts to promote male partner involvement in the prevention of mother-to-child transmission (PMTCT) may inadvertently exploit gender power differentials to achieve programme targets.

METHODS

We explored women's relative power and perceptions of male partner involvement through interviews with postpartum Zambian women living with HIV (n = 32) using a critical discourse analysis.

RESULTS

Women living with HIV reported far-reaching gender power imbalances, including low participation in household decision-making, economic reliance on husbands, and oppressive gendered sexual norms, which hindered their autonomy and prevented optimal mental and physical health during and after their pregnancy. When the husband was HIV-negative, sero-discordance exacerbated women's low power in these heterosexual couples. Male involvement in HIV care was both helpful and hurtful, and often walked a fine line between support for the woman and controlling behaviours over her. Inequities in the sexual divisions of power and labour and gender norms, combined with HIV stigma created challenging circumstances for women navigating the PMTCT cascade.

CONCLUSIONS

Future programmes should consider the benefits and risks of male partner involvement within specific relationships and according to women's needs, rather than advocating for universal male involvement in PMTCT. This work highlights the persistent need for gender transformative approaches alongside PMTCT efforts.

Delayed Disclosure of HIV Status and Lack of Resources Affect Older Persons during Care of Adult Family Members with AIDS-Related Illness in Rural Mpumalanga, South Africa

Purpose

This paper examines the older persons' knowledge of HIV and AIDS and explores the effect of delayed disclosure of HIV status and lack of resources during care.

Methods

The study site was health facilities in Thembisile Hani subdistrict, Mpumalanga Province, South Africa. Older persons aged 60 years and above were selected using purposive sampling for in-depth interviews. Thematic analysis was used to analyse the data.

Results

Providing physical care to sick adults is labour intensive for the already weak older persons. They undertake the caring role within constraints arising from lack of resource such as gloves, diapers, and soap with which to perform the caring role. Taking care of the sick needed resources for specialized care and money for transport to the health facilities. This put a strain on the finances and rendered the older persons food insecure. Furthermore, disclosure of HIV status was delayed, and some older persons cared for the sick adult children without knowing that they were HIV-infected and had AIDS-related illnesses. The nondisclosure of their HIV status by the sick prevented them from taking precautionary measures to prevent the risk of infection during the provision of care. This was heightened by the limited knowledge of HIV/AIDS of the older persons.

Conclusion

Older persons undertake the caring role with diligence under trying conditions due to lack of resources and the nondisclosure of HIV status of the adult children they take care of. Healthcare workers should educate older persons to take preventive precautionary measures when caring for family members even when there is no suspicion of HIV infection. In addition, access to the incapacity grants provided for individuals sick with AIDS-related illnesses could relieve the older persons from financial constraints.

"To die is better than to tell": reasons for and against disclosure of chronic hepatitis B status in Ghana

BACKGROUND

People with a condition subject to stigmatisation, such as chronic hepatitis B, face the dilemma of whether or not to disclose their status. In Ghana, 12.3% of the adult population has the hepatitis B virus (HBV). One key strategy for breaking the cycle of hepatitis B transmission is the disclosure of hepatitis B status by people with chronic hepatitis B (PWHB). Disclosure can facilitate preventive actions to reduce hepatitis B transmission (e.g., not sharing personal items and avoiding contact with blood and body fluids). Disclosure can also motivate family members of PWHB to get tested, linked to care and clinically managed in order to reduce the progression of hepatitis B to liver cirrhosis and cancer. Given the importance of disclosure, we set out to explore reasons for and against disclosure of chronic hepatitis B status in the Greater Accra and Upper East region of Ghana.

METHODS

In this exploratory qualitative study, 18 participants (10 from the Greater Accra region and 8 from the Upper East region) were recruited for semi-structured interviews. Interviews were recorded and transcribed verbatim. Data were then processed using QSR Nvivo version 10.0 and analysed for themes.

RESULTS

Participants were selective disclosers, disclosing in some contexts and not in others. Reasons for non-disclosure of chronic hepatitis B status were: 1) fear of stigmatisation and 2) previous negative experiences with disclosure. Reasons for disclosure were: 1) wanting close contacts to get tested or vaccinated, 2) trusting the disclosure target(s), and 3) needing social and/or financial support.

CONCLUSIONS

Our findings highlight various reasons for and against disclosure of chronic hepatitis B status in Ghana. Because anticipated, observed, and experienced stigma were important motivations for non-disclosure of chronic hepatitis B status, we recommend the development and implementation of theory and evidence-based stigma reduction interventions that are culturally appropriate, and that prioritize the participation of target populations. We also recommend the provision of counselling and support services that assist PWHB in their disclosure decision-making processes.

Factors associated with 36-month loss to follow-up and mortality outcomes among HIV-infected adults on antiretroviral therapy in Central Kenya

BACKGROUND

The scale-up of HIV treatment programs has resulted in a reduction in HIV-related morbidity and mortality. However, retention of patients in these programs remains a challenge in sub-Saharan Africa. Understanding factors associated with loss to follow-up (LTFU) and mortality outcomes is therefore important to inform targeted program interventions.

METHODS

A retrospective multi-cohort analysis of 23,890 adult patients on ART over 36 months of follow-up in Kenya was done. Multivariate logistic regression analysis was done to assess for factors associated with LTFU and mortality at 6, 12, 24, and 36 months of follow-up.

RESULTS

Majority, 67.7%, were female. At 36 months, 27.2% were LTFU and 13.5% had died. Factors associated with mortality at 36 months included older age (51 years and above) using 20-35 years as reference [(adjusted odds ratio [aOR], 1.51, 95% confidence interval (CI) 1.23-1.86, p < 0.001], being male (aOR, 1.59, 95% CI 1.39-1.83, p < 0.001), divorced using married as reference (aOR, 1.86, 95% CI 1.56-2.22, p < 0.001), having a body mass index (BMI) score of less than 18.5 kg/m2 using 18.5-24.9 kg/m2 as reference (aOR = 1.79, 95% CI 1.52-2.11, p < 0.001), and, World Health Organization stage III and IV using stage I as the reference (aOR, 1.94, 95% CI 1.43-2.63 and aOR, 4.24, 95% CI 3.06-5.87, p < 0.001 respectively). Factors associated with LTFU at 36 months included being young between 20 and 35 years (aOR, 1.49, 95% CI 1.40-1.59, p < 0.001) using 36-50 years as reference, being male (aOR, 1.19, 95% CI 1.12-1.27, p < 0.001), and being single or divorced using married as reference (aOR, 1.34, 95% CI 1.23-1.45 and aOR, 1.25, 95% CI 1.15-1.36, p < 0.001 respectively). Patients with baseline BMI of less than 18.5 kg/m2 using normal BMI as reference (aOR, 1.68, 95% CI 1.39-2.02, p < 0.001) were also likely to be LTFU.

CONCLUSIONS

Factors associated with LTFU and mortality were generally similar over time. Implementation of programs in similar settings should be tailored to gender, age profiles, nutritional, and, marital status of patients to address LTFU. In addition, programs should focus on the care of older patients to reduce the risk of mortality.

Individual Social Capital and the HIV Continuum of Care in a Rural Setting of the Southeast United States

Social capital is associated with the health of people living with HIV, and yet few studies have examined social capital in relation to the HIV continuum of care in the United States. The current study assessed individual social capital within social networks of 251 people living with HIV and residing in a rural area of the southeastern United States. Participants completed computerized self-administered measures that included markers of social capital and disclosure of HIV status to network members. We estimated individual social capital for each relationship identified in the social network interviews and tested regression models at three points along the HIV continuum of care: receiving ART, ART adherence, and HIV viral suppression. Results indicated that one in four participants had not disclosed their HIV status to at least one member of their social network and disclosure was not associated with social capital. Regression models showed that participants with larger social networks and less social capital were more likely to be receiving ART and more likely to have HIV suppressed viral loads. Alcohol use, not social capital, was related to ART non-adherence. Participant's depressive symptomatology was unrelated to any HIV care continuum metrics assessed in this study. We conclude that social capital is drawn upon at critical points along the HIV continuum of care. Interventions should focus on building social capital within social networks and provide support to key network members when patients are transitioning into care, initiating ART and experiencing HIV unsuppressed viral loads.

HIV Disclosure Patterns and Psychosocial Correlates Among People Living with HIV in Nanjing, China: A Latent Class Analysis

Little is known about the patterns of HIV disclosure and the predictors of such group memberships. Therefore, our study aimed to explore the relationship between HIV disclosure patterns and psychosocial factors. From July to August 2016, totally 466 people living with HIV (PLWH) were recruited from a tertiary hospital. Latent class analysis was performed to ascertain HIV disclosure patterns, and multinomial logistic regression was used to examine predictors of HIV disclosure patterns. Four classes were identified and characterized as the systematic disclosure (11.2%), systematic concealment (39.5%), disclosure to spouse (29.0%), and disclosure to parents (20.4%). Relative to the systematic concealment class, respondents of the systematic disclosure and disclosure to spouse classes were more likely to report a high level of social support (adjusted odds ratio (aOR) = 1.112, 95% CI = 1.039-1.189; aOR = 1.144, 95% CI = 1.084-1.208). PLWH in the disclosure to spouse class tended to have increased perceived stigma (aOR = 1.040, 95% CI = 1.008-1.073). These findings provide practical implications for effective intervention targeting the different subgroups. Urgent attention should be paid to perceived stigma and social support to encourage PLWH to disclose their HIV status.

"My Life is Spoiled Because of Him…" A Qualitative Study of Human Immunodeficiency Virus Disclosure and Male Involvement in Prevention of Mother-to-Child Transmission Program

Background:

India has the third largest human immunodeficiency virus (HIV) epidemic in the world, with 15,000 newborns infected every year. Prevention of mother-to-child transmission (PMTCT) services can eliminate new HIV infections. Nondisclosure of positive HIV status and nonoptimal uptake of PMTCT are related. Therefore, understanding different aspects of HIV disclosure are necessary for program managers and careproviders for prevention and support.

Objective:

The present research explores HIV disclosure narratives, the family's perspective, and theoretical framework in the context of PMTCT.

Methods:

A qualitative study was conducted among 31 (16 mothers and 15 fathers) utilizers of PMTCT at an urban antiretroviral therapy center. A semi-structured in-depth interview guide based on disclosure process model (DPM) was used to explore HIV disclosure goals and outcomes by both members of parental dyad. The recorded interviews were transcribed verbatim, translated into English, and analyzed with Atlas.ti software. Directed content analysis was used to code data according to “a priori” and emerging themes. Demographic data were analyzed using descriptive statistics.

Results:

Limited disclosure is a necessity for pregnant women and their male partners for approach coping with HIV diagnosis and pursuing positive support for PMTCT adherence. Interpersonal, society, and community contextual outcomes affect the care uptake and future likelihood of disclosure.

Conclusions:

DPM suggestions from the present study can be used to facilitate a goal-directed process that allows parents/PLWHA to selectively disclose their HIV status to family members and acquaintances for obtaining maximum support to eliminate newborn HIV infections while minimizing distress, stigma, and discrimination.

'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.

Change in multidimensional problems and quality of life over three months after HIV diagnosis: a multicentre longitudinal study in Kenya and Uganda

Background

Evidence on patient-reported outcomes of newly diagnosed HIV patients is scarce, and largely cross-sectional. This prospective cohort study describes the prevalence of, and changes in, patient-reported outcomes in the three months after HIV diagnosis, in 11 HIV outpatient centres in Kenya and Uganda.

Methods

Adults were recruited within 14 days of result, completing self-report measures four times at monthly intervals. Multilevel mixed-effects linear regression (quality of life continuous outcomes) and ordinal logistic regression (symptoms and concerns categorical outcomes) modelled change over time, with repeated observations grouped within individuals adjusted for demographic/clinical characteristics, and multiple imputation for missing data.

Results

438 adults were enrolled and 234 (53·4%) initiated ART. Improvement was found for MOS-HIV physical health (from 46·3 [95% CI 45·1–47·3], to 53·7 [95% CI 52.8–54·6], p < 0.001), and mental health (from 46·4 [95% CI 45·5–47·3] to 54·5 [95% CI 53·7–55·4], p < 0.001). POS subscale ‘interpersonal problems’ improved but remained burdensome (OR = 0·91, 95% CI = 0·87–0·94, p < 0.001; 22·7% reported severe problems at final time point). The scores for the existential POS subscale (OR = 0·95, 95% CI = 0.90–1·00, p = 0.056) and physical/psychological problems POS subscale (OR = 0·97, 95% CI = 0.92–1·02, p = 0.259) did not improve.

Participants who initiated ART had worsening physical/psychological (OR = 0·64, 95% CI = 0·41–0·99, p = 0·045) and interpersonal problems (OR = 0·64, 95% CI = 0·42–0·96, p = 0·033).

Conclusion

Although some self-reported outcomes improve over time, burden of interpersonal problems remains substantial and existential concerns do not improve.

The impact of HIV couple testing and counseling on social support among pregnant women and their partners in Lilongwe, Malawi: an observational study

Couples HIV testing and counseling (couple counseling) promotes safer sexual behaviors, increases communication between couples, and decreases HIV transmission. However, the impact of couple counseling on social support, critical for persons living with HIV, has not been examined. Ninety couples with a recently tested HIV-positive pregnant woman (female-positive couples) and 47 couples with a recently tested HIV-negative pregnant woman (female-negative couples) were enrolled in an observational study at an antenatal clinic in Malawi. Each couple member was assessed immediately before and one month after couple counseling for partner, family, and peer social support using the Multidimensional Scale of Perceived Social Support. Before couple counseling, social support was lower among women than men in both female-positive couples (β = -10.00, p < .01) and female-negative couples (β = -8.43, p  < .01). After couple counseling, social support increased for women in female-positive couples (β = 4.01, p < .01) and female-negative couples (β = 4.69, p < .01) but not for men in either type of couple. Couple counseling could be an effective strategy to increase social support for women, including those with recent HIV diagnoses.

ART adherence and viral suppression are high among most non-pregnant individuals with early-stage, asymptomatic HIV infection: an observational study from Uganda and South Africa

INTRODUCTION

The success of universal antiretroviral therapy (ART) access and aspirations for an AIDS-free generation depend on high adherence in individuals initiating ART during early-stage HIV infection; however, adherence may be difficult in the absence of illness and associated support.

METHODS

From March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non-pregnant women with early-stage HIV infection (CD4 > 350 cells/μL), pregnant women with early-stage HIV infection and men and non-pregnant women with late-stage HIV infection (CD4 < 200 cells/μL). Socio-behavioural questionnaires were administered and viral loads were performed at 0, 6 and 12 months. Adherence was monitored electronically.

RESULTS

Adherence data were available for 869 participants: 322 (37%) early/non-pregnant, 199 (23%) early/pregnant and 348 (40%) late/non-pregnant participants. In Uganda, median adherence was 89% (interquartile range 74 to 96) and viral suppression was 90% at 12 months; neither differed among groups (p > 0.72). In South Africa, median adherence was higher in early/non-pregnant versus early/pregnant or late/non-pregnant participants (76%, 37%, 52%; p < 0.001), with similar trends in viral suppression (86%, 51%, 79%; p < 0.001). Among early/non-pregnant individuals in Uganda, adherence was higher with increasing age and lower with structural barriers; whereas in South Africa, adherence was higher with regular income, higher perceived stigma and use of other medications, but lower with maladaptive coping and cigarette smoking.

DISCUSSION

ART adherence among non-pregnant individuals with early-stage infection is as high or higher than with late-stage initiation, supporting universal access to ART. Challenges remain for some pregnant women and individuals with late-stage infection in South Africa and highlight the need for differentiated care delivery.

Social support, disclosure and stigma and the association with non-adherence in the six months after antiretroviral therapy initiation among a cohort of HIV-positive adults in rural KwaZulu-Natal, South Africa

The World Health Organisation (WHO) recommends antiretroviral treatment (ART) initiation at human immunodeficiency virus (HIV) diagnosis. As ART programmes expand, addressing barriers to adherence is vital. Past mixed findings on the association between social support, stigma and non-disclosure with ART adherence highlights the need for further research. The primary aim of this study was to examine how these factors are associated with ART non-adherence in the six months after ART initiation. The secondary aim was to explore how other factors are associated with non-adherence. We conducted secondary analysis of prospective data from HIV-positive adults initiating ART. Social support, disclosure patterns, perceived stigma and other demographic factors were collected at ART initiation and six months follow-up. Logistic regression models were used to examine factors associated with self-reported ART non-adherence in the last six months and the last month before the six month follow-up (“recent”). Non-adherence in the last six months was twenty-five percent and recent non-adherence was nine percent. There was no association between non-adherence and social support, stigma or non-disclosure of HIV status. In the final model the odds of non-adherence in the last six months were significantly higher for those: with incomplete ART knowledge (aOR 2.10, 95%CI 1.21–3.66); who visited a healthcare provider for conditions other than HIV (aOR1.98, 95%CI 1.14–3.43); had higher CD4 counts at ART initiation (CD4 100–199:aOR 2.50, 95%CI 1.30–4.81; CD4 ≥ 200:aOR 2.85, 95%CI 1.10–7.40;referent CD4 < 100 cells/mm³); had tested HIV-positive in the last year (aOR 2.00, 95%CI 1.10–3.72; referent testing HIV-positive outside the last year); experienced a rash/itching secondary to ART (aOR 2.48, 95%CI 1.37–4.52); and significantly lower for those ≥48 years (aOR 0.65, 95%CI 0.46–0.90). Early non-adherence remains a concern. Incorporation of adherence monitoring and ART knowledge enhancement into appointments for ART collection may be beneficial.

Social Support and Violence-prone Relationships as Predictors of Disclosure of HIV Status Among Newly Diagnosed HIV-positive South Africans

Despite the salience of social support and violence as potential outcomes of disclosure, how pre-existing social support and relationship violence among people living with HIV shapes and influences HIV status disclosure has received limited attention. Following the Disclosure Process Model, this study investigated pre-disclosure support and violence-prone relationships as predictors of disclosure using data from a prospective study of 459 newly diagnosed South African women and men. Most (88%) disclosed their status to at least one person by their 8-month interview. Level of social support was unrelated to disclosure to a partner. However, those with higher levels of support had higher odds of disclosing to family and to others. Women in violence-prone relationships were more likely to report disclosure to a partner than were those not in such relationships, counter to expectations. The findings suggest that the same mechanisms may not explain processes of disclosure across all relationship types.

Reaching the First 90 in Uganda: Predictors of Success in Contacting and Testing the Named Sexual Partners of HIV+ Index Clients in Kiboga District

Assisted partner notification programs represent one strategy for targeted HIV testing and treatment of exposed individuals in high-risk populations. This study of a pilot Partner Services program in rural Uganda describes predictors of successful contact tracings and testing of partners of HIV+ individuals and possible barriers to contact. Partner contact tracing data was extracted from registers at seven Ministry of Health facilities between May and October 2016, to inform program implementation and scale up. A total of 464 HIV+ index clients named 660 sexual partners; 334/660 (51%) were contacted, 193/334 (58%) tested for HIV, and 61/193 (32%) tested HIV+. Current relationship status predicted contact [AOR = 0.23; (95% CI 0.15, 0.37), p < 0.0001] and testing [AOR = 0.19; (95% CI 0.09, 0.36), p < 0.0001]. Partner contact information type was associated with contact (p < 0.0001), and assisted disclosure with testing (p < 0.0001). Partner contact tracing is an effective means of identifying undiagnosed HIV infections.

HIV Status Disclosure Among Postpartum Women in Zambia with Varied Intimate Partner Violence Experiences

HIV-positive pregnant and postpartum women's status disclosure to male sexual partners is associated with improved HIV and maternal and child health outcomes. Yet, status disclosure remains a challenge for many women living with HIV in sub-Saharan Africa, particularly those who are fearful of violence. The objective of the present study is to advance the current understanding of the relationship between intimate partner violence against women and their HIV status disclosure behaviors. We specifically evaluate how the severity, frequency, and type of violence against postpartum HIV-positive women affect status disclosure within married/cohabiting couples. A cross-sectional survey was administered by trained local research assistants to 320 HIV-positive postpartum women attending a large public health center for pediatric immunizations in Lusaka, Zambia. Survey data captured women's self-reports of various forms of intimate partner violence and whether they disclosed their HIV status to the current male partner. Multiple logistic regression models determined the odds of status disclosure by the severity, frequency, and type of violence women experienced. Our findings indicate a negative dose-response relationship between the severity and frequency of intimate partner violence and status disclosure to male partners. Physical violence has a more pronounced affect on status disclosure than sexual or emotional violence. Safe options for women living with HIV who experience intimate partner violence, particularly severe and frequent physical violence, are urgently needed. This includes HIV counselors' ability to evaluate the pros and cons of status disclosure among women and support some women's decisions not to disclose.

A qualitative study on the experiences and perspectives of public sector patients in Cape Town in managing the workload of demands of HIV and type 2 diabetes multimorbidity

BACKGROUND

Current South African health policy for chronic disease management proposes integration of chronic services for better outcomes for chronic conditions; that is based on the Integrated Chronic Disease Model (ICDM). However, scant data exist on how patients with chronic multimorbidities currently experience the (re)-organisation of health services and what their perceived needs are in order to enhance the management of their conditions.

METHODS

A qualitative study was conducted in a community health centre treating both HIV and diabetes patients in Cape Town. The study was grounded in the Shippee's Cumulative Complexity Model (CCM) and explored "patient workload" and "patient capacity" to manage chronic conditions. Individual interviews were conducted with 10 adult patient-participants with HIV and type two diabetes (T2D) multimorbidity and 6 healthcare workers who provided health services to these patient-participants.

RESULTS

Patient-participants in this study experienced clinic-related workload such as: two separate clinics for HIV and T2D and perceived and experienced power mismatch between patients and healthcare workers. Self-care related workloads were largely around nutritional requirements, pill burden, and stigma. Burden of these demands varied in difficulty among patient-participants due to capacity factors such as: positive attitudes, optimal health literacy, social support and availability of economic resources. Strategies mentioned by participants for improved continuity of care and self-management of multi-morbidities included integration of chronic services, consolidated guidelines for healthcare workers, educational materials for patients, improved information systems and income for patients.

CONCLUSION

Using the CCM to explore multimorbidity captured most of the themes around "patient workload" and "patient capacity", and was thus a suitable framework to explore multimorbidity in this high HIV/T2D burden setting. Integration of chronic services and addressing social determinants of health may be the first steps towards alleviating patient burden and improving their access and utilisation of these services. Further studies are necessary to explore multimorbidity beyond the context of HIV/T2D.

HIV status disclosure to male partners among rural Nigerian women along the prevention of mother-to-child transmission of HIV cascade: a mixed methods study

Background

HIV status disclosure to male partners is important for optimal outcomes in the prevention of mother-to-child transmission of HIV (PMTCT). Depending on timing of HIV diagnosis or pregnancy status, readiness to disclose and disclosure rates may differ among HIV-positive women. We sought to determine rates, patterns, and experiences of disclosure among Nigerian women along the PMTCT cascade.

Methods

HIV-positive women in rural North-Central Nigeria were purposively recruited according to their PMTCT cascade status: pregnant-newly HIV-diagnosed, pregnant-in care, postpartum, and lost-to-follow-up (LTFU). Participants were surveyed to determine rates of disclosure to male partners and others; in-depth interviews evaluated disclosure patterns and experiences. Tests of association were applied to quantitative data. Qualitative data were manually analysed by theme and content using the constant comparative method in a Grounded Theory approach.

Results

We interviewed 100 women; 69% were 21–30 years old, and 86% were married. There were 25, 26, 28 and 21 women in the newly-diagnosed, in-care, postpartum, and LTFU groups, respectively. Approximately 81% of all participants reported disclosing to anyone; however, family members were typically disclosed to first. Ultimately, more women had disclosed to male partners (85%) than to family members (55%). Rates of disclosure to anyone varied between groups: newly-diagnosed and LTFU women had the lowest (56%) and highest (100%) rates, respectively (p = 0.001). However, family (p = 0.402) and male partner (p = 0.218) disclosure rates were similar between cascade groups. Across all cascade groups, fear of divorce and intimate partner violence deterred women from disclosing to male partners. However, participants reported that with assistance from healthcare workers, disclosure and post-disclosure experiences were mostly positive.

Conclusion

In our study cohort, although disclosure to male partners was overall higher, family members appeared more approachable for initial disclosure. Across cascade groups, male partners were ultimately disclosed to at rates > 75%, with no significant inter-group differences. Fear appears to be a major reason for non-disclosure or delayed disclosure by women to male partners. Augmentation of healthcare workers’ skills and involvement can mediate gender power differentials, minimize fear and shorten time to male partner disclosure among women living with HIV, regardless of their PMTCT cascade status.

Trial registration

Clinicaltrials.gov registration number NCT 01936753, September 3, 2013 (retrospectively registered).

The Voices That Influence HIV-Positive Mothers' Breastfeeding Practices in an Urban, Ghanaian Society

BACKGROUND

The World Health Organization recommends that HIV-positive mothers should breastfeed for at least 1 year. There are people in the lives of these mothers who influence their decisions. Research aim: The aim was to explore the role of social persuasion in the decision-making processes of HIV-positive breastfeeding mothers.

METHODS

A qualitative, exploratory research design was employed ( N = 13). Participants were recruited from a public hospital in the Greater Accra Region of Ghana. One-on-one interviews were recorded and transcribed verbatim, and the contents of the transcripts were analyzed for emerging themes.

RESULTS

The perspectives of spouses, health workers, counselors, and siblings about breastfeeding affect the breastfeeding practices of mothers living with HIV in Ghana. Most of the women had negative experiences with their midwives. Because of complex social and cultural influences, the opinions of spouses, health professionals, siblings, and members of the communities in which breastfeeding mothers with HIV live influence breastfeeding practices.

CONCLUSION

This study described HIV-positive, breastfeeding mothers' perceptions of the role played by spouses, health professionals, siblings, and the community in breastfeeding decisions and practices. Influential people in the lives of breastfeeding mothers with HIV should be involved during interventions by HIV counselors to promote breastfeeding practices.

HIV status disclosure among postpartum women in rural Tanzania: predictors, experiences and uptake of a nurse-facilitated disclosure intervention

HIV status disclosure is a key support strategy to start and maintain HIV care and treatment and to reduce HIV transmission. We explored the patterns and correlates of disclosure and described the effectiveness of nurse-facilitated disclosure among HIV-infected mothers of infants in coastal Tanzania. We enrolled 400 HIV positive women in an observational longitudinal study in 2011, interviewed them about maternal sociodemographic and economic characteristics, maternal and child health and history of HIV disclosure experiences and offered nurse-facilitated HIV disclosure at enrolment or at follow-up 1 month later. Mothers frequently disclosed their status to husbands and/or female relatives and experienced predominantly positive reactions. Economically vulnerable women disclosed more often to elderly female relatives, indicating that Infant and Young Child Feeding counseling given to HIV positive women should garner the support of elderly female relatives for implementing appropriate feeding practices. Nurse-facilitated disclosure was feasible in this low resource setting and was used by patients to help them with both first-time disclosure and disclosure to new persons.

Psychometric testing of the consequences of an HIV disclosure instrument in Mandarin: a cross-sectional study of persons living with HIV in Hunan, China

PURPOSE

This study aimed to examine the psychometric properties of a Mandarin-language version of an instrument that assesses the Consequences of HIV Disclosure (CoHD).

PATIENTS AND METHODS

The original CoHD instrument developed by Serovich was translated into Mandarin and administered to a random sample of 184 persons living with HIV (PLWH) using face-to-face and structured interviews. The CoHD instrument required respondents to rate the importance of eight costs (eg, might lose the relationship) and ten rewards (eg, would bring us closer) in their decision about whether to self-disclose their HIV status. The participants were directed to respond with respect to a current (or hypothetical) sexual partner.

RESULTS

Internal consistency was acceptable (Cronbach's α for the overall scale 0.82, costs 0.71, and rewards 0.86), as was stability (test-retest reliability overall 0.74, cost 0.63, and rewards 0.82). The CVI for the scale was 0.83, with items rated by subject experts ranging from 0.80 to 1.0. To determine structural validity, exploratory factor analysis extracted two subscales consistent with the original CoHD subscales. The Mandarin CoHD scores were significantly correlated with disclosure self-efficacy (indicating convergent validity), but they were unrelated to safer sex efficacy (indicating divergent validity). This criterion was tested by comparing the scores of PLWH who disclosed their HIV status (mean±SD 53.57±9.06) with those who did not disclose it (mean±SD 49.63±7.45); however, the difference was not statistically significant.

CONCLUSION

The Mandarin version of the CoHD instrument demonstrates promising psychometric properties when assessing costs and rewards with respect to sexual partner disclosure. This suggests that it might be useful in research on partner notification strategies. In further studies, larger and more diverse samples and an analysis of responses for different disclosure targets are warranted. Moreover, whether the CoHD score is related to the decision of disclosure should be determined.

Social support, stigma, and HIV disclosure among parents living with HIV in Guangxi, China

Both stigma and social support have been identified to be associated with HIV status disclosure among people living with HIV. This study aimed to examine cross-sectional associations of perceived social support and multiple types of stigma with both disclosure to various target groups and timing of disclosure among parents living with HIV (PLHIV) in Guangxi, China. Cross-sectional data from 1254 PLHIV in Guangxi, China were analyzed. Measures included demographics, disclosure to specific groups (steady partner/spouse, children, family and others) and timing of disclosure, perceived social support, and three types of HIV-related stigma (perceived, internalized, and enacted stigma). Logistic regression analyses were performed to identify the associations of interest. The participants who reported higher levels of perceived social support were more likely to have disclosed to steady partner/spouse, family or others. Those who experienced enacted stigma were more likely to have disclosed to children or family. Those who were married/cohabitating were more likely to have disclosed to steady partner/spouse, and less likely to have disclosed to children, family or others. Older PLHIV were less likely to have disclosed to steady partner/spouse, or family. Those who had a job were more likely to have disclosed to steady partner/spouse. Perceived social support appeared not to be associated with timing of disclosure. Those who disclosed within a shorter time after diagnosis were more likely to be women or have disclosed to steady partner/spouse, and less likely to have higher perceived stigma or have disclosed to family. Interventions are needed to help reduce the negative effect of perceived stigma at both family and community levels and to help enhance perceived social support in general and emotional support in particular among PLHIV, especially males and older adults.