Measuring HIV-related stigma among healthcare providers: a systematic review

General and healthcare-related HIV stigma among cisgender Brazilian women: the role of socioeconomic vulnerability

BACKGROUND

HIV-related stigma is associated with worse health outcomes and lower adherence to antiretroviral therapy. There is limited data on the stigma faced by Latin American cisgender women, although they are among the populations most affected by HIV. This study aims to provide insight into the Stigma Index Brazil, with the objective of estimating the prevalence of HIV-related stigma among cisgender women in Brazil and to investigate the role of low socioeconomic status in stigma experience.

METHODS

This is a cross-sectional community-based study. A total of 30 people with HIV were trained to recruit participants from their peer networks; 1,768 people with HIV from all regions of Brazil participated in the study, of which 566 participants were cisgender women. We used the Stigma Index, an instrument that assesses global trends in HIV-related stigma from the perspective of people with HIV.

RESULTS

Approximately 70% of participants reported some form of HIV-related stigma. The most prevalent forms were discriminatory comments or gossiping (51.26%) and verbal harassment (30.99%). More than 20% experienced any health care related HIV-stigma in the last 12 months, the most frequent being the avoidance of physical contact (10.02%). Women in social vulnerability faced more stigma compared to the group without social vulnerability, both in general contexts (75.79% vs 64.32%; χ2 = 8.67, p < 0.05) and in healthcare contexts (24.12% vs 16.02%; χ2 = 4.06, p < 0.05).

CONCLUSION

We found a high prevalence of stigma associated with HIV faced by Brazilian women from all regions of the country, both in everyday life and in healthcare contexts. Evidence-based interventions to reduce stigma in the general population, and specific mental health care aimed at women with HIV in Brazil, especially among those with greater socioeconomic vulnerability, are urgent.

Stigma in Pediatric Cancer: An Exploratory Study of Osteosarcoma and Retinoblastoma in Guatemala, Jordan, and Zimbabwe

PURPOSE

Stigma is an understudied barrier to health care acceptance in pediatric oncology. We sought to explore the stigma experience, including its impact on cancer treatment decision making, and identify strategies to mitigate stigma for patients with osteosarcoma and retinoblastoma in Guatemala, Jordan, and Zimbabwe.

METHODS

Participants included caregivers, adolescent patients (age 12-19 years), and health care clinicians. A semistructured interview guide based on The Health Stigma and Discrimination Framework (HSDF) was adapted for use at each site. Interviews were conducted in English, Spanish, Arabic, or Shona, audio-recorded, translated, and transcribed. Thematic analysis focused on stigma practices, experiences, outcomes, drivers, mitigators, and interventions.

RESULTS

We conducted 56 interviews (28 caregivers, 19 health care clinicians, nine patients; 20 in Guatemala, 21 in Jordan, 15 in Zimbabwe). Major themes were organized into categories used to adapt the HSDF to global pediatric cancer care. Themes were described similarly across all sites, ages, and diagnoses, with specific cultural nuances noted. Pediatric cancer stigma was depicted as an isolating and emotional experience beginning at diagnosis and including internalized and associative stigma. Stigma affected decision making and contributed to negative outcomes including delayed diagnosis, treatment abandonment, regret, and psychosocial fragility. Overcoming stigma led to positive outcomes including resilience, treatment adherence, pride, and advocacy. Identified stigma drivers and mitigators were linked to potential interventions.

CONCLUSION

Participants describe a shared stigma experience that transcends geography, cultural context, age, and diagnosis. Stigma manifestations have the potential to impact medical decision making and affect long-term psychological outcomes. Stigma assessment tools and interventions aimed at stigma mitigation including educational initiatives and support groups specific to pediatric cancer should be the focus of future research.

Quality of life among people living with HIV aged 50 years and over in Australia: Identifying opportunities to support better ageing

OBJECTIVES

Improved life expectancy has led to an ageing population of people living with HIV in most countries. Research on ageing among people living with HIV has predominantly focused on physical and health-related quality of life rather than multidimensional quality of life. We measured quality of life among older people living with HIV in Australia and identified opportunities to guide the development and implementation of appropriate interventions.

METHODS

In a national health and wellbeing survey of Australian people living with HIV, participants aged ≥50 years completed additional questions relevant to ageing. Quality of life was measured using PozQoL, a validated multidimensional instrument assessing quality of life among people living with HIV (range 1-5). Exploratory bivariate analyses aimed to identify sociodemographic characteristics associated with quality of life. Adjusted linear regressions aimed to assess changes in PozQoL score associated with recent experiences (last 12 months) of four exposures: food insecurity, HIV-related stigma, isolation from the HIV community, and difficulties accessing non-HIV health services.

RESULTS

Among 319 older people living with HIV, the mean PozQol score was 3.30 (95% confidence interval [CI] 3.20-3.39). In bivariate analyses, PozQol scores were significantly higher among participants who were older (p = 0.006), had higher educational attainment (p = 0.009), were in a relationship (p = 0.005), were employed (p = 0.005), and had a higher income (p = 0.001). In adjusted regression models, PozQoL scores were lower among participants who reported recent experiences of food insecurity (β -0.49; 95% CI -0.74 to -0.24), stigma (β -0.53; 95% CI -0.73 to -0.33), isolation from the HIV community (β -0.49; 95% CI -0.70 to -0.29), and difficulties accessing non-HIV health services (β -0.50; 95% CI -0.71 to -0.30).

CONCLUSIONS

Overall, older people living with HIV in this study had a moderate quality of life. Our findings suggest that HIV services should integrate programmes to support economic security and foster connections within the HIV community and across health services.

Too Close for Comfort? Attitudes of Gynecologic Oncologists Toward Caring for Dying Patients

PURPOSE

To assess gynecologic oncologists' attitudes relating to palliative care referrals among advanced cancer patients.

METHODS

Gynecologic oncologists were surveyed using validated measures to assess stigmatizing attitudes toward palliative care, anticipated stigma of palliative care, acceptance of palliative care, and willingness to refer to palliative care. Descriptive statistics were calculated. Analysis was performed using linear regression.

RESULTS

1200 physicians received the survey and 108 (9%) completed it. Most were female (69.4%) and white (82.4%). Most practiced in academics (64.8%) in urban environments (71.3%). Respondents did not have anticipated stigma surrounding palliative care referral (mean score 1.89, range 1-7, higher score indicating more stigma), were accepting of palliative care (mean score 1.45, range 1-7, higher score indicating less acceptance), and were willing to refer patients to palliative care (mean score 5.75, range 1-7, higher score indicating more willingness to refer). Linear regression demonstrated females had less anticipated stigma surrounding palliative care (B = -.213, P = .04) and higher acceptance of palliative care (B = -.244, P = .01). Most surveyed derived satisfaction from work with advanced cancer patients (83%). Nineteen percent were depressed by managing advanced cancer patients. One fourth felt emotionally burned out by dealing with too many deaths.

CONCLUSIONS

Most gynecologic oncologists did not exhibit stigma surrounding palliative care and derive satisfaction from their work. Some gynecologic oncologists experience depression and burnout related to their profession. This close connection with patients as they transition to the end of life may take a toll on providers.

Provider-patient experiences and HIV care utilization among people living with HIV who inject drugs in St. Petersburg, Russia

Providers' disrespect and abuse of patients is a recognized but understudied issue affecting quality of care and likely affecting healthcare utilization. Little research has examined this issue among people living with HIV (PWH) who inject drugs, despite high stigmatization of this population. No research has examined this issue in the context of Russia. This study assesses patients' reports of disrespect and abuse from providers as a barrier to healthcare and examines the association between these reports and HIV care outcomes.We conducted a cross-sectional analysis of the associations between disrespect/abuse from health providers as a barrier to care and the following HIV care outcomes: (i) anti-retroviral treatment (ART) uptake ever, (ii) past 6-month visit to HIV provider, and (iii) CD4 count. Participants (N = 221) were people living with HIV who injected drugs and were not on ART at enrollment.Two in five participants (42%) reported a history disrespect/abuse from a healthcare provider that they cited as a barrier to care. Those reporting this concern had lower odds of ever use of ART (adjusted odds ratio 0.46 [95% CI 0.22, 0.95]); we found no significant associations for the other HIV outcomes. We additionally found higher representation of women among those reporting prevalence of disrespect/abuse from provider as a barrier to care compared to those not reporting this barrier (58.1% versus 27.3%).Almost half of this sample of PWH who inject drugs report disrespect/abuse from a provider as a barrier to healthcare, and this is associated with lower odds of receipt of ART but not with other HIV outcomes studied. There is need for improved focus on quality of respectful and dignified care from providers for PWH who inject drugs, and such focus may improve ART uptake in Russia.

Understanding geriatric models of care for older adults living with HIV: a scoping review and qualitative analysis

BACKGROUND

Advances in Human Immunodeficiency Virus (HIV) treatment have reduced mortality rates and consequently increased the number of individuals with HIV living into older age. Despite this, people aged 50 years and older have been left behind in recent HIV treatment and prevention campaigns, and a gold-standard model of care for this population has not yet been defined. Developing evidence-based geriatric HIV models of care can support an accessible, equitable, and sustainable HIV health care system that ensures older adults have access to care that meets their needs now and in the future.

METHODS

Guided by Arksey & O'Malley (2005)'s methodological framework, a scoping review was conducted to determine the key components of, identify gaps in the literature about, and provide recommendations for future research into geriatric models of care for individuals with HIV. Five databases and the grey literature were systematically searched. The titles, abstracts and full texts of the search results were screened independently in duplicate. Data were analyzed using a qualitative case study and key component analysis approach to identify necessary model components.

RESULTS

5702 studies underwent title and abstract screening, with 154 entering full-text review. 13 peer-reviewed and 0 grey literature sources were included. Most articles were from North America. We identified three primary model of care components that may improve the successful delivery of geriatric care to people living with HIV: Collaboration and Integration; Organization of Geriatric Care; and Support for Holistic Care. Most articles included some aspects of all three components.

CONCLUSION

To provide effective geriatric care to older persons living with HIV, health services and systems are encouraged to use an evidence-based framework and should consider incorporating the distinct model of care characteristics that we have identified in the literature. However, there is limited data about models in developing countries and long-term care settings, and limited knowledge of the role of family, friends and peers in supporting the geriatric care of individuals living with HIV. Future evaluative research is encouraged to determine the impact of optimal components of geriatric models of care on patient outcomes.

Police Stigma toward People with Opioid Use Disorder: A Study of Illinois Officers

BackgroundFatal opioid overdoses continue to break historical records. Stigma toward people with opioid use disorder (OUD) can negatively impact treatment access, retention, and recovery. Attitudes and beliefs of police officers can profoundly shape key discretionary decisions. Therefore, we examined police officer views indicating stigma toward those with OUD.ObjectivesWe administered an online survey to select Illinois police departments using a stratified random sampling strategy with a final sample of 248 officers from 27 police departments. We asked officers questions measuring stigmatizing attitudes toward people with OUD including distrust, blame, shame, and fear. We found officers held somewhat stigmatizing views with a mean score of 4.0 on a scale of 1 (least stigmatic) to 6 (most stigmatic).ResultsRegression results showed certain officer characteristics were associated with more stigmatizing attitudes of blaming and distrust of those with OUD, including gender, education, race, years in policing, and department size.Conclusions/ImportanceSince most officers in the sample held at least some stigmatizing views toward people with OUD, this may impede the feasibility and acceptability of criminal justice interventions meant to improve behavioral health, such as police deflection programs that link people who use drugs to treatment in lieu of arrest. Departments should offer officer training and education on substance use disorders, treatment for addiction, and the potential for a person's recovery. Training should allow officers to hear directly from, or learn about, personal experiences of people who use drugs and have been in recovery, as this type of interaction has been shown to reduce stigma.

The Influence of Anticipated HIV Stigma on Health-related Behaviors, Self-rated Health, and Treatment Preferences Among People Living with HIV in East Asia

Long-acting injectable regimens for HIV treatment have been developed which are less frequent, more discreet, and more desirable for some people living with HIV (PLHIV) and may help reduce stigma-related barriers to HIV treatment. However, there is little information on the relationship between reported stigma and preference for these newer treatments. We characterized anticipated, experienced, and internalized HIV stigma and examined the associations with treatment preferences among an international sample of PLHIV. Data came from the international, web-based, cross-sectional study called "Positive Perspectives" conducted among PLHIV aged ≥ 18 years in 25 geographic locations during 2019 (n = 2389). Descriptive analyses were stratified among East Asian (n = 230) vs. non-Asian (n = 2159) participants. Results showed that prevalence of anticipated stigma was significantly higher among East Asian than non-Asian participants (72.2%[166/230] vs. 63.8%[1377/2159], p = 0.011). A significantly higher percentage of East Asian (68.7%[158/230]) than non-Asian participants (43.3%[935/2159] indicated that someone finding their HIV pills would cause them much "stress or anxiety" (p < 0.001). Actions taken by some PLHIV to prevent unwanted disclosure included restricting who they shared their HIV status with, hiding their HIV pills, or even skipping a dose altogether because of privacy concerns. Overall, 50.0%[115/230] East Asian participants believed HIV would reduce their lifespan and 43.0%[99/230] no longer planned for their old age because of HIV. Anticipated stigma was strongly associated with receptivity to non-daily regimens. Concerted efforts to reduce stigma and deliver flexible treatment options that address the unmet treatment needs of PLHIV, including confidentiality concerns, may improve their health-related quality of life.

“Nothing is ever going to change if we don't start advocating for our child.”: Community-level disclosure and stigma management strategies among parents of internationally adopted children living with PHIV

Background

The number of internationally adopted children living with perinatally-acquired HIV (IACP) in the U.S. is increasing, yet little is known about their families' experiences navigating HIV disclosure within a community context. This paper examines the lived experiences of adoptive parents as they navigate HIV disclosure and manage stigma toward their adopted children within their broader communities.

Methods

A purposive sample of parents of IACP was recruited at two pediatric infectious disease clinics and via closed Facebook groups. Parents completed two semi-structured interviews approximately one year apart. Interview questions included strategies parents used to reduce the impact of community level stigma that their child is likely to encounter as they mature. Interviews were analyzed using Sort and Sift, Think and Shift analytic approach. All parents (n = 24) identified as white and most (n = 17) had interracial families, with children adopted from 11 different countries (range: age at adoption 1-15 years; range: age at first interview 2-19 years).

Results

Analyses revealed that parents serve as advocates for their child by both supporting more public HIV disclosure at times, but also applying indirect strategies such as working to improve outdated sex education material. Knowledge of HIV disclosure laws empowered parents to make informed decisions about who, if anyone, in the community needed to know their child's HIV status.

Conclusion

Families with IACP would benefit from HIV disclosure support/training and community-based HIV stigma reduction interventions.

The relationship between HIV-related stigma and HIV self-management among men who have sex with men: The chain mediating role of social support and self-efficacy

HIV infection becomes a manageable disease, and self-management is one of the key indicators of achieving optimal health outcomes. Men who have sex with men (MSM) living with HIV face many psychosocial challenges when managing HIV infection, such as sexual minority pressure and HIV-related stigma. Higher perceived HIV-related stigma had been related to low self-management. However, the mechanisms underlying the association between HIV-related stigma and HIV self-management are unclear. Two possible mediators include social support and self-efficacy. This study aimed to examine the relationship between HIV-related stigma and HIV self-management among MSM living with HIV and to explore the single mediating effect of social support and self-efficacy and the chain mediating effect of these two variables on this relationship in China. Convenience sampling was used to recruit participants from the Center for Disease Control (CDC) in Changsha City, Hunan province, China. A total of 459 MSM living with HIV completed questionnaires regarding sociodemographic and disease-related information, HIV-related stigma, social support, self-efficacy, and HIV self-management. Descriptive statistics analysis, one-way ANOVA, independent t-tests, Pearson's bivariate correlation, and multiple regression were conducted using the SPSS v24.0. Process macro in SPSS was used to analyze the single and chain mediating effect among variables. Our findings showed that the indirect and total effect of HIV-related stigma on HIV self-management was significant, while the direct effect was not statistically significant. Social support and self-efficacy mediated the relationship between HIV-related stigma and HIV self-management, respectively. Moreover, the chain mediating model confirmed that the association between HIV-related stigma and HIV self-management was mediated by social support and self-efficacy sequentially. Future interventions focusing on improving HIV self-management among MSM living with HIV should consider a multi-faced approach.

HIV-related stigma among healthcare providers working within infectious diseases and gynecology and obstetrics at a large teaching hospital in Denmark

HIV-related stigma experienced in healthcare settings may be particularly detrimental to people with HIV (PWH). This study aims to examine the drivers of stigma and enacted HIV-related stigma among healthcare providers working in HIV and non-HIV care at a large teaching hospital in Denmark. In total, 162 providers working in gynecology and obstetrics, and 57 providers working in infectious diseases completed the "Measuring HIV stigma and discrimination among health facility staff" questionnaire. Compared to providers working in infectious diseases, providers working in gynecology and obstetrics had less training in infection control, HIV, and stigma, and although their level of worry and negative attitudes toward PWH was overall low, they were more like to use extra precaution measures (e.g., double gloves) when caring for PWH (20% versus 0%). Addressing HIV-related stigma in healthcare is important, as any amount of HIV-related stigma from providers has the potential to compromise the patients' engagement in care and health outcomes.

Psychometric evaluation of the Health Care Provider HIV/AIDS Stigma Scale (HPASS) using Rasch analysis

INTRODUCTION

The role of pharmacists is crucial in the care of individuals with HIV/AIDS. However, stigma in health care settings can be a deterrent to providing appropriate care. This paper assessed psychometric properties and convergent validity of the Health Care Provider HIV/AIDS Stigma Scale (HPASS) among pharmacy students in the United States (US) using Rasch analysis.

METHODS

Students enrolled in four US universities were administered the survey (N = 203). Rasch analysis was conducted for each HPASS subscale (Stereotyping, Discrimination, and Prejudice) to assess dimensionality, model data fit, item difficulty, individual stigma, distribution of items and persons across item-person map, and rating scale function. Convergent validity evidence was established by comparing Pearson's correlation coefficients between HPASS subscales and the AIDS Attitude Scale (AAS) Avoidance subscale.

RESULTS

Two items in the Prejudice subscale were misfit and therefore removed. The 6-point rating scale did not perform satisfactorily for HPASS subscales. Item difficulty ranges were wide [Stereotyping (-5 to 0.8 logits), Discrimination (-6 to 1 logits), Prejudice (-5 to 0.4 logits)]. Items were biased towards measuring higher levels of stigma. Person separation index was satisfactory (Stereotyping = 2.2; Discrimination = 2.06; Prejudice = 2.17) as was person separation reliability (Stereotyping = 0.83; Discrimination = 0.81; Prejudice = 0.83). Convergent validity was established by showing significant correlations between HPASS subscales and AAS Avoidance (P < .001).

CONCLUSIONS

Modifying or removing misfit items of HPASS and exploring alternate rating scales for HPASS subscales will help better assess HIV/AIDS related stigma among pharmacy students.

A study on the adaptation of the HIV/AIDS-related Stigma Scale into Turkish

PURPOSE

This study aims to test the validity and reliability of the Turkish version of the HIV/AIDS-related Stigma Scale.

DESIGN AND METHODS

The study has a methodological design. The sample included a total of 428 participants. of the participants, 198 were HIV/AIDS patients, 230 were HIV-negative individuals. The data were analyzed using the Exploratory and Confirmatory Factor Analysis.

FINDINGS

The Turkish version of the HIV/AIDS-related Stigma Scale was found to be valid and reliable for the Turkish society. Cronbach's α was 0.93 for the community perspectives subscale and 0.89 for the patient perspectives subscale, and all the model fit indices were acceptable.

PRACTICE IMPLICATIONS

The level of stigmatization revealed by the scale helps gain an insight into the community and patient perspectives on HIV/AIDS.

Conocimientos y percepción de estudiantes de psicología sobre el trabajo profesional en personas con VIH

Los psicólogos que se dedican a la atención de personas diagnosticadas con VIH es necesario que cuenten con una actitud favorable hacia el trabajo profesional que impacte en una mejor atención; además es necesario que como profesionales de la salud, también tengan un comportamiento sexual saludable, de tal manera que haya congruencia entre lo que hace y lo que transmite como profesional. Con base en lo anterior, se tienen dos objetivos: (1) conocer el nivel de conocimientos sobre VIH/SIDA, creencias y uso del condón en relaciones sexuales estudiantes de psicología; y (2) conocer su percepción sobre VIH y del trabajo profesional con personas diagnosticadas con VIH. Se evaluó a 439 estudiantes de psicología, en términos generales se encontró que tienen un nivel aceptable de conocimientos sobre VIH, pero no sobre el uso del condón; tienen creencias favorables hacia su uso, pero no implica que sean consistentes en su uso; también se encontró una valoración positiva hacia la atención de personas con VIH. Se discute en términos de la importancia de formar a los estudiantes sobre la importancia de su salud sexual y en cómo trabajar con personas con VIH.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

INTRODUCTION

There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.

METHODS AND ANALYSIS

Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.

PROSPERO REGISTRATION NUMBER

CRD42021249348.

A qualitative study of the stigmatization and coping mechanisms among pregnant teenagers living with HIV in Thailand

Purpose

This aim of this study was to explore the experiences of stigmatization and coping mechanisms during pregnancy among pregnant women who are living with HIV in Thailand. The secondary objective was to determine factors contributing to stigma during motherhood among HIV-infected women as well as explore how they cope with the discrimination from society.

Design/methodology/approach

Qualitative data were collected using in-depth interviews to obtain different versions of stigmatized experience from 16 pregnant women living with HIV on stigmatization and coping mechanisms. There were 5 pregnant adolescents living with HIV and 11 adult pregnant women living with HIV. The content analysis was used to examine patterns of stigmatizations and attributed factors.

Findings

Personal stigma was found among pregnant women living with HIV regardless of age. HIV status disclosure was the crucial barrier of accessing to care for people experiencing stigmatizations. Personal stigma associated with higher HIV status was not disclosed. Interestingly, all teenage mothers who participated in this study disclosed their HIV-status to their family. People who have social support especially from family and significant others are found to be able to cope and get through the difficulties better than those who lack those social support.

Originality/value

This study yields outcomes similar to several other studies that have been conducted either in Thailand or other countries. This study found that family support was crucial in reducing HIV stigma. Furthermore, HIV-infected pregnant female adults were more afraid to disclose their HIV status to their husbands, other family members and their work colleagues.

Consensus statement on the role of health systems in advancing the long-term well-being of people living with HIV

Health systems have improved their abilities to identify, diagnose, treat and, increasingly, achieve viral suppression among people living with HIV (PLHIV). Despite these advances, a higher burden of multimorbidity and poorer health-related quality of life are reported by many PLHIV in comparison to people without HIV. Stigma and discrimination further exacerbate these poor outcomes. A global multidisciplinary group of HIV experts developed a consensus statement identifying key issues that health systems must address in order to move beyond the HIV field's longtime emphasis on viral suppression to instead deliver integrated, person-centered healthcare for PLHIV throughout their lives.

Therapeutic Borderlands: Austerity, Maternal HIV Treatment, and the Elusive End of AIDS in Mozambique

"End of AIDS" requires ambitious testing, treatment, and adherence benchmarks, like UNAIDS' "90-90-90 by 2020." Mozambique's efforts to improve essential maternal/infant antiretroviral treatment (ART) exposes how austerity-related health system short-falls impede public HIV/AIDS service-delivery and hinder effective maternal ART and adherence. In therapeutic borderlands-where household impoverishment intersects with health-system impoverishment-HIV+ women and over-worked care-providers circumnavigate scarcity and stigma. Worrisome patterns of precarious use emerge-perinatal ART under-utilization, delayed initiation, intermittent adherence, and low retention. Ending HIV/AIDS requires ending austerity and reinvesting in a public sector health workforce to ensure universal health coverage as household and community safety nets.

HIV-related stigma in the UK then and now: to what extent are we on track to eliminate stigma? A qualitative investigation

Background

The introduction of effective antiretroviral treatment in the late 1990s led to the perception that HIV was a chronic but manageable condition. Nevertheless, stigma remains one of the major hurdles for people living with HIV (PLWH) to accessing healthcare and biomedical preventions. Thus, Fast Track Cities has set a target of zero HIV discrimination by 2030 as part of its strategy to end HIV transmission.

Methods

Fifty-three participants from the United Kingdom, including PLWH (n = 21, 40%), health and social care workers (n = 24, 45%), and charity workers and activists (n = 13, 25%), were recruited. Semi-structured interviews investigated stigma and discrimination, focusing on both before and after the widespread use of effective antiretroviral treatment in the late 1990s. Data were analysed using a thematic approach.

Results

Before effective antiretroviral treatment narratives were shaped by two main themes: 1) the media’s role in influencing public opinion and contributing to misunderstandings of HIV transmission; and 2) personal experiences of HIV-related stigma, which for PLWH included incidents of physical violence and aggression, as well as fears of their HIV status being publicised. Contemporary narratives on stigma experiences were organised around four themes: 1) discrimination in healthcare settings; 2) stigma amongst men who have sex with men (MSM); 3) stigma towards African and Afro-Caribbean PLWH; and 4) the limits of change in public HIV-related knowledge and attitudes. Contemporary narratives indicated a reduction in enacted stigma, but continued anticipation of discrimination and self-reported shame, particularly in MSM and African and Afro-Caribbean PLWH.

Conclusion

The nature of stigma against those with HIV has evolved. The intersection of PLWH and minority groups (e.g. MSM and African and Afro-Caribbean persons) may enhance anticipatory and internalised stigma, with some suggestion that this may contribute to reduced engagement in HIV care and prevention services. Our findings indicate the need for further research in this area, as well as proactive interventions with community groups to enhance knowledge of HIV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11000-7.

Lived experiences of people living with HIV: a descriptive qualitative analysis of their perceptions of themselves, their social spheres, healthcare professionals and the challenges they face daily

BACKGROUND

Human immunodeficiency virus (HIV) infection rates have been gradually increasing in Istanbul, Turkey. Many people living with HIV (PLWH) here encounter difficulties, for example, in adapting to the chronic disease and obtaining continuous access to healthcare services. In this study, we aimed to explore the challenges PLWH face in their daily lives and understand their perceptions of themselves, healthcare professionals and services, and their social spheres via their expressed lived experiences in the healthcare setting.

METHOD

Individual semi-structured in-depth interviews were conducted face-to-face with 20 PLWH in Istanbul. All the interviews were voice-recorded and transcribed verbatim except one, upon participant request, for which the interviewer took notes. These logs and the interviewer's notes were analyzed thematically using the inductive content analysis method.

RESULTS

The themes concerned experiences in three distinct contexts: 1) Interactions with healthcare providers; 2) Participants' responses to their HIV diagnosis; and 3) Interactions with their social networks. Firstly, the results highlighted that the participants perceived that healthcare professionals did not inform them about the diagnosis properly, failed to protect patients' confidentiality and exhibited discriminative behaviors towards them. Secondly, after the diagnosis the participants had difficulty in coping with their unsettled emotional state. While many ceased sexual activities and isolated themselves, some sought support. Lastly, living with HIV affected their relationships with their families and friends either positively or negatively. Moreover, they had to face the difficulties concerning spouse/partner notification issues about which many needed professional support.

CONCLUSION

Healthcare professionals' discriminative or inappropriate attitudes and customs in healthcare institutions are perceived to impair PLWH's utilization of healthcare services. Structural factors such as social pressure, societal ignorance about HIV, limited access to HIV prevention, and regulatory barriers might contribute to these challenges. The results suggest that it is necessary to raise healthcare professionals' and society's awareness about HIV and develop national policies to establish a well-functioning referral system and appropriate spouse/partner notification services.

Increasing the Donor Pool: Organ Transplantation from Donors with HIV to Recipients with HIV

Implementation of the HIV Organ Policy Equity (HOPE) Act marks a new era in transplantation, allowing organ transplantation from HIV+ donors to HIV+ recipients (HIV D+/R+ transplantation). In this review, we discuss major milestones in HIV and transplantation which paved the way for this landmark policy change, including excellent outcomes in HIV D-/R+ recipient transplantation and success in the South African experience of HIV D+/R+ deceased donor kidney transplantation. Under the HOPE Act, from March 2016 to December 2018, there were 56 deceased donors, and 102 organs were transplanted (71 kidneys and 31 livers). In 2019, the first HIV D+/R+ living donor kidney transplants occurred. Reaching the full estimated potential of HIV+ donors will require overcoming challenges at the community, organ procurement organization, and transplant center levels. Multiple clinical trials are ongoing, which will provide clinical and scientific data to further extend the frontiers of knowledge in this field.

Key and general population HIV-related stigma and discrimination in HIV-specific health care settings: results from the Stigma Index Brazil

HIV-related stigma and discrimination lead to poorer mental health, lower levels of services usage, and less adherence to antiretroviral medications. Due to the overlap of different kinds of stigmas, HIV-positive key populations are the most susceptible to negative health outcomes. The Stigma Index is an instrument that measure worldwide trends in HIV-related stigma from the perspective of people living with HIV/AIDS (PLWHA). The present community-based study aims to estimate the prevalence of HIV-related discrimination in the past 12 months in HIV-related care, comparing general and key populations in Brazil. A total of 30 PLWHA were trained to recruit participants among their peer networks; 1768 PLWHA participated in the study and were asked if, in the past 12 months when seeking HIV-specific healthcare, they had experienced discrimination from health facility staff because of their HIV status. Overall, 269 (15.21%) participants experienced this kind of discrimination. The odds of experiencing discrimination in HIV-specific healthcare settings in the general versus key populations was OR 1.77 95% CI [1.30 -2.42]. It is noteworthy that in Brazil, after four decades of a human rights-based approach to the epidemic, we found high levels of discrimination in the HIV-specific healthcare context affecting the key populations more severely.

Unmet needs of symptom management and associated factors among the HIV-positive population in Shanghai, China: A cross-sectional study

BACKGROUND

People living with HIV/AIDS (PLWHA) are a vulnerable group who experience multiple physiological and psychological symptoms. A better understanding of unmet symptom management needs will allow researchers to design interventions that are more reflective of deficits in care and more effective at improving patient care. Few studies have focused on unmet needs for symptom management in PLWHA particularly in China. Factors influencing Chinese PLWHA symptom management needs are rarely discussed.

AIM

The purpose of this study was to investigate the unmet needs for symptom management of PLWHA and how their symptom burden, HIV perceived stigma, and self-management capacity contributes to HIV-related self-management practices in Shanghai, China.

DESIGN

Study participants were recruited from the outpatient and inpatient HIV/AIDS wards in an infectious hospital in Shanghai, China. Self-administered questionnaires were implemented and medical charts were reviewed.

RESULTS

A total of 367 participants was recruited from April to September 2017. The results show that 53.1% (195 of 367) of participants presented at least one unmet symptom management need and that symptom burden, as well as perceived stigma, reduced self-management capacity, and no employment significantly affected unmet symptom management needs.

CONCLUSION

The findings indicate that there is room for improvement in symptom management for Chinese PLWHA. Culturally appropriate interventions focusing on improving symptom burden, decreasing HIV perceived stigma, and enhancing self-management capacity can enhance symptom management in this population.

Thirty-Five Years Later: HIV Stigma in Washington, DC Health Care Workers

Stigma has negatively influenced the lives of people living with HIV since the beginning of the epidemic. It affects every facet of their lives and can cause mental health problems, loss of human rights, and barriers to care. Studies in developing countries have shown a high prevalence of HIV stigma among health care workers. Few studies have been conducted in the United States. We used a validated instrument to survey 330 health care workers in Washington, DC, a high HIV prevalence area. The goal was to obtain data to assess the severity of the problem. We found that stigmatizing beliefs and attitudes were prevalent as reflected in responses from 66% of the participants. Of clinicians surveyed, 31% reported using double gloves. Participants with stigma training had lower stigma levels, whereas older individuals and support staff were more stigmatizing. Negative attitudes affect access to care and have major public health implications.

Multilevel Barriers to Engagement in the HIV Care Continuum Among Residents of the State of Rhode Island Living with HIV

An estimated 1.2 million people in the United States are living with HIV. Of those living with HIV, only 40% are engaged in HIV care, 37% are prescribed antiretroviral therapy (ART), and 30% are virally suppressed. Individual-, interpersonal-, and structural-level factors that represent barriers to engagement along the HIV care continuum are important to identify in order to inform priority areas and interventions. 296 adult residents of Rhode Island living with HIV between November 2015 and January 2016 were asked to participate in an observational study (Ryan White Part B Health Resources and Services Administration-funded consumer needs assessment) to identify the multilevel factors associated with engagement in the HIV care continuum outcomes (i.e., being retained in care, being prescribed ART, adhering to ART, and achieving viral suppression-all in the past 12 months). Multivariable logistic regression models were fit to model the four HIV care continuum outcomes. The majority of participants were over age 30 (92.5%), racial/ethnic minorities (67.1%), cisgender men (56.9%), and identified as straight/heterosexual (60.5%). Overall, 95.2% of participants were retained in care in the past 12 months, 93.0% were prescribed ART, 87.1% were currently adherent to ART, and 68.2% were virally suppressed. Factors positively associated with not being retained in HIV care in the past 12 months included having no income and challenges navigating the HIV care system. Being age 18-29 and having a provider who does not know how to treat people with HIV/AIDS were each positively associated with not being prescribed ART. Factors positively associated with not being adherent to ART included being age 18-29 and substance use in the past 12 months. Finally, having private insurance and having a provider who is not trustworthy were each positively associated with not being virally suppressed. Regardless of the fact that many of the individuals living with HIV in this sample are able to achieve an undetectable viral load, challenges with retention in HIV care and ART adherence threaten to undermine the clinical and public health benefits of treatment as prevention. Future longitudinal research conducted to better understand how to boost the effectiveness of treatment as prevention in this population should focus on examining the unique multilevel factors, polymorbidities, and conditions (mostly social determinants of health including housing, socioeconomic position, etc.) associated with suboptimal engagement across the stages of the HIV care continuum.

Stigma interdependence among pregnant HIV-infected couples in a cluster randomized controlled trial from rural South Africa

BACKGROUND

Stigma can exacerbate negative health outcomes in people living with HIV (PLWH). This longitudinal, cluster randomized controlled trial in rural Mpumalanga, South Africa, examined the interdependence of HIV-related stigma among pregnant couples living with HIV, and the potential impact of a lay health worker delivered intervention, Protect Your Family, on changes in stigma over time across couples, controlling for physical intimate partner violence (IPV), verbal IPV, gender, HIV knowledge, and months since HIV diagnosis. Using a form of the Actor-Partner Interdependence model, changes in stigma over time were also examined within each dyad of seroconcordant participants with HIV.

METHOD

Antenatal clinics were randomized to experimental or control conditions, and participants completed baseline antenatal and 12-month postpartum assessments. Both women and male partners participated in intervention sessions in gender concordant groups and couple or individual sessions.

RESULTS

Multilevel models (N = 1475) revealed stigma was related to condition and verbal intimate partner violence, but not time. Using an Actor-Partner Interdependence cross-lagged path model to examine within dyad changes in stigma for seroconcordant couples (n = 201), intervention condition participants' stigma levels were not interdependent over time. Women's 12-month stigma was related to their partners' stigma at baseline in the control condition, but not in the intervention condition.

DISCUSSION

Compared to women in the control condition, postpartum stigma among women in the intervention condition was not related to their male partners' stigma, suggesting that women's perception of stigma became uncoupled from that of their partners. The intervention may have promoted female empowerment to shape their own beliefs and attitudes towards what it means to be infected with HIV, and express their own agency in responding to how others treat them and they treat themselves.

Percepção dos profissionais de saúde e dos usuários sobre o aconselhamento no teste rápido para HIV

RESUMO Objetivo Analisar a percepção acerca do aconselhamento no contexto do teste rápido para o HIV. Método Pesquisa com abordagem qualitativa realizada no Centro de Testagem e Aconselhamento com profissionais de saúde e com usuários do Centro de Testagem e Aconselhamento. A análise seguiu os passos propostos na fenomenologia empírica de Giorgi articulando-a com a literatura. Resultados Identificaram-se cinco categorias: a experiência anterior à realização do Teste Rápido; Intencionalidade de sentimentos; Percepção do aconselhamento pelo usuário; Percepção do aconselhamento individual no pós-teste e; Percepção de profissionais sobre o aconselhamento. O aconselhamento coletivo é percebido pelos usuários como palestra sobre HIV/Aids com ênfase em consequências negativas; e o aconselhamento individual, como mais confortável e como possibilidade para exposição de dúvidas. Discussão Considera-se que, mesmo sabendo da importância do aconselhamento, este é realizado de forma empírica, reduzindo o ato ao repasse de informações com teor educativo, visando apenas à aprendizagem cognitiva como meio de disseminar o conhecimento, tentando, assim, reduzir a cadeia de transmissão da HIV/Aids.

Assessing the Efficacy of a PhotoVoice-Informed HIV Stigma Training for Health Care Workers

HIV stigma is a harmful social phenomenon present in United States (US)-based health care settings. This study assessed the efficacy of a participatory PhotoVoice-informed stigma reduction training program focusing on people living with HIV (PLWH) and targeting health care workers. Seventy-three (N = 73) participants were assessed at baseline (T1), within approximately a week of the training (T2), and at a 3-month follow-up (T3) regarding their HIV/AIDS knowledge, attitudes towards PLWH, and observations of enacted HIV stigma. Findings indicated that the training increased knowledge and improved attitudes (β = 0.56, p < 0.01; β = 0.58, p < 0.01, respectively) at T2, but these effects diminished at T3 (β = - 0.03, p > 0.05; β = - 0.29, p > 0.05, respectively). The training did not, however, have an impact on observations of enacted stigma at T2 (β = 0.10, p > 0.05) or at T3 (β = 0.02, p > 0.05). Additional participatory stigma reduction programs that involve diverse groups of health care workers, offer salient study incentives, include time-saving training methods, and comprise a variety of stigma measures, may be particularly beneficial.

Barriers to HIV Treatment Adherence: A Qualitative Study of Discrepancies Between Perceptions of Patients and Health Providers in Tanzania and Uganda

Previous qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers-particularly in low-income countries-who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n = 148), and with health care providers (n = 49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (e.g., they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.

A quality improvement approach to the reduction of HIV-related stigma and discrimination in healthcare settings

HIV-related stigma and discrimination (S&D) in healthcare settings represents a potent barrier to achieving global aims to end the HIV epidemic, particularly in Southeast Asia (Cambodia, Lao People’s Democratic Republic, Thailand and Vietnam). Evidence-based approaches for measuring and reducing S&D in healthcare settings exist, but their incorporation into routine practice remains limited, in part due to a lack of attention to how unique organisational practices—beyond the knowledge and attitudes of individuals—may abet and reinforce S&D. Application of a quality improvement (QI) approach in which facilities leverage routine measurement of S&D among healthcare workers and people living with HIV, team-based learning, root cause analysis, and tests of change offers a novel means through which to address S&D in local contexts and develop interventions to address individual-level and organisation-level drivers of S&D. To support the adoption of a QI approach to S&D reduction, the Southeast Asia Stigma Reduction QI Learning Network was launched with Ministries of Health from Cambodia, Lao PDR, Thailand and Vietnam, to co-develop strategies for implementing QI activities in participating facilities. Since the inception of Network activities in 2017, Ministry-led QI activities to address S&D have been implemented in 83 facilities and 29 provinces across participating countries. Moreover, 27 strategies and interventions have been tested to date and are being evaluated for scale up by participating facilities, spanning multiple drivers and organisational domains. Lessons learned through Network activities offer national-level and facility-level HIV programmes best practices for implementing a QI approach to S&D reduction.

Understanding Global HIV Stigma and Discrimination: Are Contextual Factors Sufficiently Studied? (GAPRESEARCH)

Stigma and discrimination are among the greatest challenges that people living with human immunodeficiency virus (HIV) face, and both are known to negatively affect quality of life as well as treatment outcomes. We analyzed the growing research and current understanding of HIV-related stigma and contextual factors in HIV/AIDS (human Immunodeficiency virus/ acquired immunodeficiency syndrome) bibliography. A total of 5984 publications published from 1991 to 2017 were retrieved from the Web of Science database. The number of papers and their impacts have been considerably grown in recent years. Research landscapes related to stigma and discrimination include clinical, physical and mental health outcomes, risk behaviors of most-at-risk populations, and HIV-related services. We found a lack of empirical studies not only on social, cultural and economic contexts, but also on specific interventions for particular settings and sub-populations. This study highlights certain gaps and provides a basis for future studies and interventions on this critical issue given the changing drivers of HIV epidemics.

A Mixed Methods Study of Anticipated and Experienced Stigma in Health Care Settings Among Women Living with HIV in the United States

Among places where people living with HIV experience and anticipate HIV-related stigma, stigma in health care settings may be particularly harmful. Utilizing an exploratory sequential mixed methods approach, we conducted interviews (n = 76) and questionnaires (N = 460) with older adult women living with HIV enrolled in the Women's Interagency HIV Study in Birmingham, AL; Jackson, MS; Atlanta, GA; and San Francisco, CA. Interviews addressed facilitators and barriers to HIV treatment adherence, including HIV-related stigma. Qualitative data were coded using thematic analysis. Questionnaires assessed self-reported antiretroviral therapy (ART) adherence and experienced and anticipated HIV-related stigma from various sources (i.e., health care personnel, family, partner, and community). Covariate-adjusted logistic regression analyses examined total and mediated effects of stigma on ART adherence. Interviewees described fears and experiences of stigma in health care settings; including privacy violations, disrespect for patient autonomy, and reproductive coercion; and how these influenced their adherence to HIV treatment recommendations. Experienced and anticipated HIV-related stigma in health care settings were associated with suboptimal (or <95%) ART adherence in separate models controlling for experienced or anticipated stigma, respectively, from other sources. When entered together, only anticipated stigma in health care settings was associated with suboptimal ART adherence, controlling for anticipated and experienced stigma from other sources. The effect of anticipated stigma in health care settings on suboptimal ART adherence may work through the pathways of lower adherence self-efficacy, higher depressive symptoms, and higher coping by substance use. These findings indicate that interventions should promote cultures of acceptance within health care settings and resilience-based strategies for women to combat stigma and promote life-sustaining behaviors.

HIV-Related Stigma by Healthcare Providers in the United States: A Systematic Review

Reducing HIV-related stigma may enhance the quality of HIV prevention and care services and is a national prevention goal. The objective of this systematic review was to identify studies of HIV-related stigma among healthcare providers. For studies published between 2010 and 2017, we: (1) searched databases using our keywords, (2) excluded nonpeer reviewed studies, (3) limited the findings to the provider perspective and studies conducted in the United States, (4) extracted and summarized the data, and (5) conducted a contextual review to identify common themes. Of 619 studies retrieved, 6 were included, with 3 themes identified: (1) attitudes, beliefs, and behaviors (n = 6), (2) quality of patient care (n = 3), and (3) education and training (n = 2). Factors associated with HIV-related stigma varied by gender, race, provider category, and clinical setting. Providers with limited recent HIV-stigma training were more likely to exhibit stigmatizing behaviors toward patients. Developing provider-centered stigma-reduction interventions may help advance national HIV prevention and care goals.

Perceptions of alcohol use in the context of HIV treatment: a qualitative study

Background

Alcohol use is associated with poor HIV treatment outcomes. This study aimed to understand patients’ perceptions of the impact of alcohol use in the context of HIV care.

Methods

The study design was a descriptive qualitative study of HIV positive individuals receiving antiretroviral treatment. The study involved four focus group discussions with male and female participants at a tertiary center, city clinic, and rural church. We employed convenience sampling and invited patients coming for their routine visits and medication refills to participate.

Results

Participants had an awareness of both the direct and indirect effects of alcohol use. The direct effects related to the incompatibility of HIV medication and alcohol. The indirect effects related to the negative impact of alcohol on treatment adherence. Participants proffered reasons why HIV infected individuals on HIV treatment drink and felt that patients had to make a deliberate choice to stop drinking. Participants displayed some knowledge of interventions for drinking cessation and highlighted the use of pharmacological interventions to stop drinking. Participants indicated that they preferred HIV counselors to provide counseling services in view of the existing relationships that patients had with counselors.

Conclusion

People living with HIV have adequate knowledge of the effects of alcohol use in the context of HIV treatment. Stigma and the time taken to engage in an alcohol use intervention appeared to be the main impediments to uptake. The current model of HIV treatment, based on trust with the HIV care team, and maintenance of this trust, could bolster the uptake of an intervention. Involvement of HIV patients in their treatment is necessary to improve treatment outcomes in the context of alcohol use.