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Aggarwal A, Zhang R, Qiao S, Wang B, Lwatula C, Menon A, Ostermann J, Li X, Harper G. Physician-Patient Interaction Quality Mediates the Association Between HIV-Related Stigma and HIV-Prevention Behaviors Among Sexual Minority Men in Zambia. AIDS Behav 2024; 28:1559-1569. [PMID: 37874436 DOI: 10.1007/s10461-023-04171-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/25/2023]
Abstract
HIV-related stigma is a major challenge to HIV prevention for sexual minority men (SMM) in Zambia, but little is known about the underlying mechanisms. This study aimed to investigate whether physician-patient interaction quality mediates the relationship between HIV-related stigma and HIV-prevention behaviors among SMM. Data were collected using a cross-sectional survey from 194 SMM (aged: mean = 24.08, SD = 4.27) across four districts in Zambia between February and November 2021. Participants were asked about their demographic characteristics, HIV-related stigma, SMM-related stigma, physician-patient interaction quality, HIV-testing intention, and use of pre-exposure prophylaxis (PrEP). Path analysis was used to test the mediation effect of physician-patient interaction quality in the associations of HIV-related stigma/SMM-related stigma with HIV-testing intention and current PrEP use. Higher self-reported physician-patient interaction quality was negatively associated with HIV-related stigma (β = - 0.444, z = - 2.223, p < 0.05), and positively associated with HIV-testing intention (β = 0.039, z = 5.121, p < 0.001) and current PrEP use (β = 0.008, z = 2.723, p < 0.01). HIV-related stigma among SMM had a significant and negative indirect effect on HIV-testing intention (β = - 0.017, z = - 2.006, p < 0.05), and current PrEP use (β = - 0.004, z = - 2.009, p < 0.05) through physician-patient interaction quality. Contrary to our expectations, SMM-related stigma did not have a significant and negative indirect effect on HIV prevention behaviors through physician-patient interaction quality. Health interventions need to improve physician-patient interaction quality by offering healthcare provider training, targeting HIV-related stigma in healthcare settings, and devising inclusive healthcare policies to promote HIV prevention efforts.
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Affiliation(s)
- Abhishek Aggarwal
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Ran Zhang
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Shan Qiao
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA.
| | - Bo Wang
- Population and Quantitative Health Sciences, University of Massachusetts, Boston, USA
| | | | - Anitha Menon
- Department of Psychology, University of Zambia, Lusaka, Zambia
| | - Jan Ostermann
- Department of Health Service Policy and Management, University of South Carolina, Columbia, USA
| | - Xiaoming Li
- Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, USA
| | - Gary Harper
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, USA
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Mulenga DM, Rosen JG, Banda L, Musheke M, Mbizvo MT, Raymond HF, Keating R, Witola H, Phiri L, Geibel S, Tun W, Pilgrim N. "I Have to Do It in Secrecy": Provider Perspectives on HIV Service Delivery and Quality of Care for Key Populations in Zambia. J Assoc Nurses AIDS Care 2024; 35:27-39. [PMID: 38019138 PMCID: PMC10842367 DOI: 10.1097/jnc.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
ABSTRACT Key populations (KPs) experience suboptimal outcomes along the HIV care and prevention continua, but there is limited study of the challenges service providers encounter delivering HIV services to KPs, particularly in settings like Zambia, where provision of these services remains legally ambiguous. Seventy-seven providers completed in-depth interviews exploring constraints to HIV service delivery for KPs and recommendations for improving access and care quality. Thematic analysis identified salient challenges and opportunities to service delivery and quality of care for KPs, spanning interpersonal, institutional, and structural domains. Limited provider training in KP-specific needs was perceived to influence KP disclosure patterns in clinical settings, impeding service quality. The criminalization of KP sexual and drug use behaviors, coupled with perceived institutional and legal ambiguities to providing HIV services to KPs, cultivated unwelcoming service delivery environments for KPs. Findings elucidate opportunities for improving HIV service delivery/quality, from decentralized care to expanded legal protections for KPs and service providers.
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Affiliation(s)
| | - Joseph G. Rosen
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | - Henry F. Raymond
- Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Piscataway, NJ, USA
| | - Ryan Keating
- Institute for Global Health Sciences, University of California, San Francisco, CA, USA
| | - Harold Witola
- National HIV/AIDS/STI/TB Council, Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
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Qiao S, Garrett CM, Addo PNO, Adeagbo O, Moore DM, Muttau N, Sharma A, Lwatula C, Ngosa L, Kabwe M, Manasyan A, Menon JA, Weissman S, Li X, Harper GW. The Impacts of Stigma Against Sexual Minority Men Within and Between Various Socioecological Levels: Breaking the Vicious Cycle in Zambia. Am J Mens Health 2023; 17:15579883231209190. [PMID: 37909703 PMCID: PMC10621297 DOI: 10.1177/15579883231209190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 09/13/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023] Open
Abstract
Sexual minority men (SMM) face persistent stigma in Zambia. From a holistic perspective, we aim to explore its impacts within and between multiple socioecological levels, demonstrating how their interactions create a vicious cycle of barriers to the well-being of SMM. In-depth interviews were conducted with 20 purposively recruited SMM from Lusaka, Zambia. All interviews were audio-recorded, after written consent, transcribed verbatim, and iteratively coded employing inductive (i.e., data-driven) approaches for thematic analysis using NVivo. Results suggest three key themes: (1) interpersonal socially perpetuated sexual minority stigma (SMS); (2) multidirectional interactions between psychosocial well-being and risk-taking behaviors; and (3) institutionally perpetuated SMS as a barrier to seeking and receiving health care. SMS permeates across all levels of the socioecological model to negatively impact the psychosocial well-being of SMM while acting also as a barrier to accessing HIV prevention and care. Our study necessitates structural public health intervention to decrease stigma and discrimination against SMM in Zambia, in efforts to increase their psychosocial well-being as well as their access to and utilization of HIV care by breaking the vicious cycle of SMS that pervades through the intrapersonal, interpersonal, and institutional levels of the socioecological model.
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Affiliation(s)
- Shan Qiao
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Camryn M. Garrett
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Prince N. O. Addo
- Department of Epidemiology, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Oluwafemi Adeagbo
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
- Department of Community and Behavioral Health, College of Public Health, The University of Iowa, Iowa City, IA, USA
| | - Darius M. Moore
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Nobutu Muttau
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Anjali Sharma
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Levy Ngosa
- Dignitate Zambia Limited (DZL), Lusaka, Zambia
| | | | - Albert Manasyan
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
- School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Sharon Weissman
- Department of Internal Medicine, School of Medicine Columbia, University of South Carolina, Columbia, SC, USA
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Gary W. Harper
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Karver TS, Barrington C, Donastorg Y, Perez M, Gomez H, Page KR, Celentano DD, Smith KC, Kerrigan D. Exploring the dynamics of the quality of HIV care experienced by female sex workers living in the Dominican Republic. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001479. [PMID: 37115734 PMCID: PMC10146439 DOI: 10.1371/journal.pgph.0001479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 03/28/2023] [Indexed: 04/29/2023]
Abstract
Despite increased attention and efforts to improve HIV care among female sex workers (FSWs), they continue to have suboptimal HIV outcomes. Exploring the socio-structural dynamics related to the quality of HIV care received by FSWs is critical to further strengthen interventions to improve their HIV care continuum outcomes. In this study, we conducted two rounds of qualitative in-depth interviews with 20 FSWs living with HIV in the Dominican Republic to explore how healthcare experiences contributed to their quality of HIV care. Data was analyzed using a thematic analytic approach exploring diverse structural and relational aspects of the quality of HIV care affecting FSWs as they navigate the clinic environment. Results indicated that quality of HIV care was influenced by both structural and relational factors within clinics. At the structural level, insufficient stock of antiretroviral therapy and the financial burden created by HIV care related costs hindered FSWs' satisfaction with their current HIV care and presented a barrier in FSWs' ability to access HIV care services. Quality of care was also closely linked to relational aspects of the HIV care environment, including FSWs' relationship and communication with their clinical providers, as FSWs often expressed their satisfaction with HIV care experiences based on these interpersonal factors. Lastly, personal agency emerged as an important factor contributing to the quality of HIV care, specifically as FSWs' treatment literacy resulted in greater advocacy and demands for quality care. Programmatic efforts should be directed to improving the quality of HIV care experiences of FSWs in the clinic environment. These include addressing resource shortages, promoting positive and effective patient-provider relationships, and facilitating HIV treatment education opportunities for FSWs.
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Affiliation(s)
- Tahilin Sanchez Karver
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Yeycy Donastorg
- Instituto Dermatológico y Cirugía de la Piel “Dr. Huberto Bogaert Díaz”, HIV Vaccine Trials Research Unit, Santo Domingo, Dominican Republic
| | - Martha Perez
- Instituto Dermatológico y Cirugía de la Piel “Dr. Huberto Bogaert Díaz”, HIV Vaccine Trials Research Unit, Santo Domingo, Dominican Republic
| | - Hoisex Gomez
- Instituto Dermatológico y Cirugía de la Piel “Dr. Huberto Bogaert Díaz”, HIV Vaccine Trials Research Unit, Santo Domingo, Dominican Republic
| | - Kathleen R. Page
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - David D. Celentano
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Katherine Clegg Smith
- Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Deanna Kerrigan
- Department of Prevention and Community Health, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, United States of America
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Mulavu M, Anitha Menon J, Mulubwa C, Matenga TFL, Nguyen H, MacDonell K, Wang B, Mweemba O. Psychosocial challenges and coping strategies among people with minority gender and sexual identities in Zambia: health promotion and human rights implications. Health Psychol Behav Med 2023; 11:2173201. [PMID: 36818391 PMCID: PMC9930791 DOI: 10.1080/21642850.2023.2173201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Background Sexual and gender minorities face high levels of stigma, discrimination, and violence. In many countries, they are often criminalized and are at risk of mental health challenges. In Zambia, little is known about the psychosocial challenges and coping strategies of sexual and gender minorities. This study sought to explore psychosocial challenges and coping strategies among sexual and gender minority populations in Lusaka, Zambia to inform mental health and human rights promotion for this population. Methods The study used a qualitative phenomenological study design. Data were collected through in-depth interviews with 16 sexual and gender minority participants (lesbian, gay, bisexual, and transgender) and four key informants. The sexual minorities included four lesbian, five gay, and three bisexual participants while the gender minorities included two transgender men and two transgender women. Interviews with gender and sexual minorities were mostly focused on the lived experiences of participants, while those of key informants focused on their work with sexual and gender minorities. Snowball strategy was used to recruit participants, while purposive sampling was used to select key informants. All interviews were recorded and transcribed verbatim. Thematic analysis was carried out with the aid of Nvivo 12 software. Results Psychosocial challenges included victimization in the form of threats and physical assault. Stigma and discrimination were experienced in different settings such as healthcare, the workplace, and school. Participants reported having experienced feelings of depression. Rejection from family members was experienced by those who revealed their sexual or gender minority status. Reported coping strategies included social support, self-concealment, listening to music, and substance use. Conclusion This study suggests that sexual and gender minorities in Zambia experience various psychosocial challenges related to their sexuality and gender identity. To assist them cope better with the obstacles they experience, improved psychosocial counseling and mental health services are needed.
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Affiliation(s)
- Mataanana Mulavu
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Lusaka, Zambia, Mataanana Mulavu Department of Health Promotion and Education, School Of Public Health, University of Zambia, P.O Box 50110, Lusaka, Zambia
| | - J. Anitha Menon
- Department of Psychology, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia
| | - Chama Mulubwa
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Tulani Francis L. Matenga
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Hoa Nguyen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Karen MacDonell
- Department of Behavioral Sciences and Social Medicine, Centre for Translational Behavioral Science, Florida State College of Medicine, FL, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Oliver Mweemba
- Department of Health Promotion and Education, School of Public Health, University of Zambia, Lusaka, Zambia
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Arinaitwe B, Ariho P, Naturinda CH, Byoleko B, Base A, Atwijukiire H, Matavu H, Kabami J, Obua C, Wakida EK, Otwine A. Enrollment and retention of female sex workers in HIV care in health facilities in Mbarara city. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 4:1089663. [PMID: 36743824 PMCID: PMC9890177 DOI: 10.3389/frph.2022.1089663] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 12/12/2022] [Indexed: 01/19/2023] Open
Abstract
Background Sex work is a global driver of the HIV epidemic, and the risk of acquiring HIV is 13 times higher for female sex workers (FSWs) compared to the general population. The enrollment and retention of FSWs in HIV care is a challenge and has been a major contributing factor to increased new HIV infections. Methods We conducted a qualitative study among 30 FSWs and 21 healthcare workers (HCWs) working in antiretroviral therapy (ART) clinics at the selected three primary health facilities in Mbarara City, Southwestern Uganda. The study participants were enrolled by both purposive and snowball sampling techniques. We obtained informed consent from all the participants, and data were collected using in-depth interviews and thematically analyzed. Results Three themes emerged as facilitators toward enrollment and retention of FSWs into HIV care, namely, (1) good health living, (2) receptive HCWs and availability of health services, and (3) community outreach services and peer support. The barriers are summarized into four major themes: (1) stigma, community discrimination, and beliefs; (2) social obstacles; (3) adverse effects of ART; and (4) inadequate services at the health facilities. Conclusion FSWs are challenged by unsupportive environments and communities where they live and work, which hinders their enrollment and retention in HIV care. Creating awareness of the utilization of HIV care services and extending such services to hotspot communities could enhance the response of HIV-positive FSWs to ART.
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Affiliation(s)
- Bridget Arinaitwe
- Department of Nursing Science, Bishop Stuart University, Mbarara, Uganda
| | - Philbert Ariho
- Department of Nursing Science, Bishop Stuart University, Mbarara, Uganda
| | | | - Brian Byoleko
- Department of Nursing Science, Bishop Stuart University, Mbarara, Uganda
| | - Anitah Base
- Department of Nursing Science, Bishop Stuart University, Mbarara, Uganda
| | | | - Hariat Matavu
- Department of Public Health and Biomedical Sciences, Bishop Stuart University, Mbarara, Uganda
| | - Jane Kabami
- Department of Nursing, Kabale University, Kabale, Uganda
| | - Celestine Obua
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edith K. Wakida
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Anne Otwine
- Department of Public Health and Biomedical Sciences, Bishop Stuart University, Mbarara, Uganda,Correspondence: Anne Otwine
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Endalamaw A, Gilks CF, Ambaw F, Habtewold TD, Assefa Y. Universal Health Coverage for Antiretroviral Treatment: A Review. Infect Dis Rep 2022; 15:1-15. [PMID: 36648855 PMCID: PMC9844463 DOI: 10.3390/idr15010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Universal health coverage is essential for the progress to end threats of the acquired immunodeficiency syndrome epidemic. The current review assesses the publication rate, strategies and barriers for antiretroviral therapy (ART) coverage, equity, quality of care, and financial protection. We searched Web of Science, PubMed, and Google Scholar. Of the available articles, 43.13% were on ART coverage, 40.28% were on financial protection, 10.43% were on quality of care, and 6.16% were on equity. A lack of ART, fear of unwanted disclosure, lack of transportation, unaffordable health care costs, long waiting time to receive care, and poverty were barriers to ART coverage. Catastrophic health care costs were higher among individuals who were living in rural settings, walked greater distances to reach health care institutions, had a lower socioeconomic status, and were immunocompromised. There were challenges to the provision of quality of care, including health care providers' inadequate salary, high workload and inadequate health workforce, inappropriate infrastructure, lack of training opportunities, unclear division of responsibility, and the presence of strict auditing. In conclusion, ART coverage was below the global average, and key populations were disproportionally less covered with ART in most countries. Huge catastrophic health expenditures were observed. UHC contexts of ART will be improved by reaching people with poor socioeconomic status, delivering appropriate services, establishing a proper health workforce and service stewardship.
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Affiliation(s)
- Aklilu Endalamaw
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
- College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
- Correspondence: ; Tel.: +61-424-690-121
| | - Charles F Gilks
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Fentie Ambaw
- School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar P.O. Box 79, Ethiopia
| | - Tesfa Dejenie Habtewold
- Branch of Epidemiology, Division of Population Health Research, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD 20892, USA
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9712 CP Groningen, The Netherlands
| | - Yibeltal Assefa
- School of Public Health, The University of Queensland, Brisbane, QLD 4072, Australia
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Wiginton JM, Mathur S, Gottert A, Pilgrim N, Pulerwitz J. Hearing From Men Living With HIV: Experiences With HIV Testing, Treatment, and Viral Load Suppression in Four High-Prevalence Countries in Sub-Saharan Africa. Front Public Health 2022; 10:861431. [PMID: 35651865 PMCID: PMC9149263 DOI: 10.3389/fpubh.2022.861431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/21/2022] [Indexed: 12/02/2022] Open
Abstract
Engaging men in HIV services remains a challenge across sub-Saharan Africa. There is a critical need to better understand facilitators of men's successful engagement with HIV services and assess if there are similarities across contexts. We conducted in-depth interviews and focus group discussions with 92 men living with HIV (MLHIV) across Malawi, Uganda, South Africa, and Eswatini, most of whom had been diagnosed with HIV within the last 5 years. We coded interviews for themes using a constant-comparative approach. We contextualized our findings within a socioecological framework. HIV testing was primarily motivated by illness (individual level), though illness was sometimes accompanied by prompting and support from healthcare providers and/or intimate partners. Once diagnosed, nearly all participants reported immediate linkage to care, initiation of antiretroviral therapy (ART), and subsequent ART adherence. ART initiation and adherence were facilitated by men's sense of agency and ownership over their health (individual level), social support from intimate partners, friends, and family (interpersonal/network level), supportive-directive counseling from healthcare providers (institutional/health systems level), and male-friendly services, i.e., rapid, respectful, private (institutional/health systems level). Health literacy regarding viral suppression (individual level), strengthened by patient-provider communication (institutional/health systems level), was highest in Uganda, where most men could discuss viral load testing experiences, report their viral load status (most reported suppressed), and demonstrate an understanding of treatment as prevention. Elsewhere, few participants understood what viral load suppression was and even fewer knew their viral load status. Our findings reveal socioecological-level facilitators of men's progress across the HIV-care continuum. Programs may want to leverage facilitators of ART initiation and adherence that span socioecological levels—e.g., healthcare ownership and agency, social support, supportive-directive counseling—and apply them to each end of the continuum to encourage early HIV testing/diagnosis and improve health literacy to help men understand and achieve viral load suppression.
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Affiliation(s)
- John Mark Wiginton
- Department of Health, Behavior and Society, Johns Hopkins University, Baltimore, MD, United States
| | | | - Ann Gottert
- Population Council, Washington, DC, United States
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Ndione AG, Procureur F, Senne JN, Cornaglia F, Gueye K, Ndour CT, Lépine A. Sexuality-Based Stigma and Access to Care: Intersecting Perspectives Between Health Care Providers and Men Who Have Sex With Men in HIV Care Centres in Senegal. Health Policy Plan 2022; 37:587-596. [PMID: 35147679 PMCID: PMC9113117 DOI: 10.1093/heapol/czac010] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 01/18/2022] [Accepted: 02/10/2022] [Indexed: 11/23/2022] Open
Abstract
Men who have sex with men (MSM) in Senegal face a challenging socio-legal context, marked by homophobia and the illegality of homosexuality. In addition, human immunodeficiency virus (HIV) prevalence among MSM is 27.6%, 46 times greater than the one in the general population (0.5%). Nevertheless, access to healthcare by MSM may be hampered by stigmatizing attitudes from health facility staff (medical and non-medical). This article describes the health facility staff/MSM relationship and analyses its effects on access to healthcare by MSM. The data used were collected through a field survey based on observations and qualitative interviews conducted in 2019 and 2020 with 16 MSM, 1 non-governmental organization (NGO) staff and 9 healthcare providers in Dakar (the capital city) and Mbour (secondary city on the West Coast) hospitals. The data were subject to a thematic analysis assisted by the ATLAS software. The relationship between MSM and healthcare providers is ambiguous. On the one hand, healthcare providers are torn between their professional duty to treat MSM and the cost of being stigmatized by other colleagues. Therefore, they often limit their empathy with MSM within the hospital context. On the other hand, MSM, trusting in the confidentiality of healthcare providers, feel safe in the care pathway. However, we identify the following stigmatizing factors limiting access to care include (1) fear of meeting a relative, (2) difficult relationships with non-medical support staff (mainly security guards), (3) HIV status disclosure and (4) potential conflicts with other MSM. This study is unique as it includes non-medical staff in its respondents. It shows that hospitals are divided into several areas, based on the stigma perceived by MSM. It is important to map out MSM’s care trajectories and spaces and to identify all types of staff working within them, including non-medical staff, and enrol them in stigma reduction interventions.
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Affiliation(s)
| | | | | | | | - Khady Gueye
- Ministry of Health and Social Action of Senegal
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10
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Nakiganda LJ, Bell S, Grulich AE, Serwadda D, Nakubulwa R, Poynten IM, Bavinton BR. Understanding and managing HIV infection risk among men who have sex with men in rural Uganda: a qualitative study. BMC Public Health 2021; 21:1309. [PMID: 34218799 PMCID: PMC8254907 DOI: 10.1186/s12889-021-11365-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 06/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Same-sex sexual relations are criminalised in Uganda, and men who have sex with men (MSM) experience a high burden of HIV infection. In Uganda, health promotion policies focus on equity in healthcare and creating enabling environments. At present there is limited evidence upon which to enhance engagement of MSM in rural settings into effective HIV prevention. To fill this gap, our study explored MSM’s understandings of HIV risk and strategies used to reduce HIV risk in their sexual lives. Methods In-depth interviews were conducted with sixteen MSM in rural communities in Southwestern Uganda. Inductive thematic analysis examined men’s perceptions of HIV risk and strategies of reducing their own HIV risks. Results Understandings of HIV risk and risk practices were framed by lack of access to condoms, challenges negotiating condom and pre-exposure prophylaxis (PrEP) use, and condomless sex being reported as more pleasurable than sex with condoms. Strategies men perceived as enabling them to manage HIV risk included: PrEP use; condom use; knowing partners’ HIV status; avoiding partners associated with HIV risk; oral sex; withdrawal before ejaculation and washing one’s penis after sex. There were several misconceptions arising from poor HIV prevention knowledge. Strategies reliant on communication and negotiation with sexual partners were inhibited by gendered powered imbalances. Conclusions Our findings illustrate that MSM in rural settings in Uganda are making concerted efforts to implement strategies that might reduce risk of HIV transmission and infection within their sexual relationships. Key HIV health promotion and service-related strategies to support MSM with these efforts include an effective condom and lubricant supply chain; a PrEP program in trusted local health units, implemented via discreet community-outreach mechanisms; and same-sex specific HIV-related health promotion.
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Affiliation(s)
| | - Stephen Bell
- UQ Poche Centre for Indigenous Health, The University of Queensland, Brisbane, Australia.,School of Public Health, The University of Queensland, Brisbane, Australia.,Centre for Social Research in Health, UNSW Sydney, Kensington, Australia
| | | | - David Serwadda
- Rakai Health Sciences Program, Kalisizo, Uganda.,Makerere University School of Public Health, Kampala, Uganda
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11
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Comprehensive approach to HIV/AIDS testing and linkage to treatment among men who have sex with men in Curitiba, Brazil. PLoS One 2021; 16:e0249877. [PMID: 33970929 PMCID: PMC8110178 DOI: 10.1371/journal.pone.0249877] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 03/29/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction The Curitiba (Brazil)-based Project, A Hora é Agora (AHA),
evaluated a comprehensive HIV control strategy among men who have sex with
men (MSM) aimed at expanding access to HIV rapid testing and linking
HIV-positive MSM to health services and treatment. AHA’s approach included
rapid HIV Testing Services (HTC) in one mobile testing unit (MTU); a local,
gay-led, non-governmental organization (NGO); an existing government-run
health facility (COA); and Internet-based HIV self-testing. The objectives
of the paper were to compare a) number of MSM tested in each strategy, its
positivity and linkage; b) social, demographic and behavioral
characteristics of MSM accessing the different HTC and linkage services; and
c) the costs of the individual strategies to diagnose and link MSM to
services. Methods We used data for 2,681 MSM tested at COA, MTU and NGO from March 2015 to
March 2017. This is a cross sectional comparison of the demographics and
behavioral factors (age group, race/ethnicity, education, sexually
transmitted diseases, knowledge of AHA services and previous HIV test).
Absolute frequencies, percentage distributions and confidence intervals for
the percentages were used, as well as unilateral statistical tests. Results and discussion AHA performed 2,681 HIV tests among MSM across three in-person strategies:
MTU, NGO, and COA; and distributed 4,752 HIV oral fluid tests through the
self-testing platform. MTU, NGO and COA reported 365 (13.6%) HIV positive
diagnoses among MSM, including 28 users with previous HIV diagnosis or on
antiretroviral treatment for HIV. Of these, 89% of MSM were eligible for
linkage-to-care services. Linkage support was accepted by 86% of positive
MSM, of which 66.7% were linked to services in less than 90 days. The MTU
resulted in the lowest cost per MSM tested ($137 per test), followed by
self-testing ($247). Conclusions AHA offered MSM access to HTC through innovative strategies operating in
alternative sites and schedules. It presented the Curitiba HIV/AIDS
community the opportunity to monitor HIV-positive MSM from diagnosis to
treatment uptake. Self-testing emerged as a feasible strategy to increase
MSM access to HIV-testing through virtual tools and anonymous test kit
delivery and pick-up. Cost per test findings in both the MTU and
self-testing support expansion to other regions with similar epidemiological
contexts.
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12
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Lo J, Nwafor SU, Schwitters AM, Mitchell A, Sebastian V, Stafford KA, Ezirim I, Charurat M, McIntyre AF. Key Population Hotspots in Nigeria for Targeted HIV Program Planning: Mapping, Validation, and Reconciliation. JMIR Public Health Surveill 2021; 7:e25623. [PMID: 33616537 PMCID: PMC7939933 DOI: 10.2196/25623] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/31/2020] [Accepted: 01/02/2021] [Indexed: 11/13/2022] Open
Abstract
Background With the fourth highest HIV burden globally, Nigeria is characterized as having a mixed HIV epidemic with high HIV prevalence among key populations, including female sex workers, men who have sex with men, and people who inject drugs. Reliable and accurate mapping of key population hotspots is necessary for strategic placement of services and allocation of limited resources for targeted interventions. Objective We aimed to map and develop a profile for the hotspots of female sex workers, men who have sex with men, and people who inject drugs in 7 states of Nigeria to inform HIV prevention and service programs and in preparation for a multiple-source capture-recapture population size estimation effort. Methods In August 2018, 261 trained data collectors from 36 key population–led community-based organizations mapped, validated, and profiled hotspots identified during the formative assessment in 7 priority states in Nigeria designated by the United States President’s Emergency Plan for AIDS Relief. Hotspots were defined as physical venues wherein key population members frequent to socialize, seek clients, or engage in key population–defining behaviors. Hotspots were visited by data collectors, and each hotspot’s name, local government area, address, type, geographic coordinates, peak times of activity, and estimated number of key population members was recorded. The number of key population hotspots per local government area was tabulated from the final list of hotspots. Results A total of 13,899 key population hotspots were identified and mapped in the 7 states, that is, 1297 in Akwa Ibom, 1714 in Benue, 2666 in Cross River, 2974 in Lagos, 1550 in Nasarawa, 2494 in Rivers, and 1204 in Federal Capital Territory. The most common hotspots were those frequented by female sex workers (9593/13,899, 69.0%), followed by people who inject drugs (2729/13,899, 19.6%) and men who have sex with men (1577/13,899, 11.3%). Although hotspots were identified in all local government areas visited, more hotspots were found in metropolitan local government areas and state capitals. Conclusions The number of key population hotspots identified in this study is more than that previously reported in similar studies in Nigeria. Close collaboration with key population–led community-based organizations facilitated identification of many new and previously undocumented key population hotspots in the 7 states. The smaller number of hotspots of men who have sex with men than that of female sex workers and that of people who inject drugs may reflect the social pressure and stigma faced by this population since the enforcement of the 2014 Same Sex Marriage (Prohibition) Act, which prohibits engaging in intimate same-sex relationships, organizing meetings of gays, or patronizing gay businesses.
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Affiliation(s)
- Julia Lo
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States.,Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Samuel U Nwafor
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Abuja, Nigeria
| | - Amee M Schwitters
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Abuja, Nigeria
| | - Andrew Mitchell
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Victor Sebastian
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Abuja, Nigeria
| | - Kristen A Stafford
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States.,Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, United States.,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | | | - Man Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, United States.,Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Anne F McIntyre
- Division of Global HIV & TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, United States
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13
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Dong N, Chen WT, Lu H, Zhu Z, Hu Y, Bao M. Unmet needs of symptom management and associated factors among the HIV-positive population in Shanghai, China: A cross-sectional study. Appl Nurs Res 2020; 54:151283. [PMID: 32425335 PMCID: PMC7229465 DOI: 10.1016/j.apnr.2020.151283] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 02/24/2020] [Accepted: 05/05/2020] [Indexed: 01/21/2023]
Abstract
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.
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Affiliation(s)
- Ning Dong
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Wei-Ti Chen
- School of Nursing, University of California, Los Angeles, CA, United States
| | - Hongzhou Lu
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China.
| | - Zheng Zhu
- School of Nursing, Fudan University, Shanghai, China
| | - Yan Hu
- School of Nursing, Fudan University, Shanghai, China
| | - Meijuan Bao
- Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
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14
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Fleming T, Valleriani J, Ng C, Maher L, Small W, McNeil R. Acceptability of a hypothetical preventative HIV vaccine among people who use drugs in Vancouver, Canada. BMC Public Health 2020; 20:1081. [PMID: 32646390 PMCID: PMC7350753 DOI: 10.1186/s12889-020-09202-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 07/02/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND As research on HIV vaccines continues to advance, studies exploring the feasibility of this intervention are necessary to inform uptake and dissemination strategies with key populations, including people who use drugs (PWUD). METHODS We conducted 25 in-depth qualitative interviews examining HIV vaccine acceptability among PWUD in Vancouver, Canada. Participants were recruited from an ongoing prospective cohort of HIV-negative PWUD. Data were coded using NVivo, and analyzed thematically. RESULTS Acceptability was framed by practical considerations such as cost and side effects, and was influenced by broader trust of government bodies and health care professionals. While an HIV vaccine was perceived as an important prevention tool, willingness to be vaccinated was low. Results suggest that future vaccine implementation must consider how to minimize the burden an HIV vaccine may place on PWUD. Centering the role of health care providers in information dissemination and delivery may assist with uptake. CONCLUSIONS Our findings suggest improvements in care and improved patient-provider relationships would increase the acceptability of a potential HIV vaccine among this population.
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Affiliation(s)
- Taylor Fleming
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Interdisciplinary Graduate Studies Program, University of British Columbia, Vancouver, BC, Canada
| | - Jenna Valleriani
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- National Institute for Cannabis Health and Education, Toronto, ON, Canada
| | - Cara Ng
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
| | - Lisa Maher
- The Kirby Institute for Infection and Immunity, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- The Burnet Institute, Melbourne, VIC, Australia
| | - Will Small
- British Columbia Centre on Substance Use, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, Vancouver, BC, Canada.
- Department of Medicine, Yale School of Medicine, New Haven, CT, USA.
- Program in Addiction Medicine, Yale School of Medicine, Yale University, 367 Cedar Street, New Haven, CT, USA.
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15
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King R, Sebyala Z, Ogwal M, Aluzimbi G, Apondi R, Reynolds S, Sullivan P, Hladik W. How men who have sex with men experience HIV health services in Kampala, Uganda. BMJ Glob Health 2020. [PMCID: PMC7245422 DOI: 10.1136/bmjgh-2019-001901] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In sub-Saharan Africa, men who have sex with men (MSM) are socially, largely hidden and face disproportionate risk for HIV infection. Attention to HIV epidemics among MSM in Uganda and elsewhere in sub-Saharan Africa has been obscured by repressive governmental policies, criminalisation, stigma and the lack of basic epidemiological data describing these epidemics. In this paper, we aim to explore healthcare access, experiences with HIV prevention services and structural barriers to using healthcare services in order to inform the acceptability of a combination HIV prevention package of services for men who have sex with men in Uganda. We held focus group discussions (FGDs) with both MSM and healthcare providers in Kampala, Uganda, to explore access to services and to inform prevention and care. Participants were recruited through theoretical sampling with criteria based on ability to answer the research questions. Descriptive thematic coding was used to analyse the FGD data. We described MSM experiences, both negative and positive, as they engaged with health services. Our findings showed that socio-structural factors, mediated by psychological and relational factors impacted MSM engagement in care. The socio-structural factors such as stigma, homophobia and policy issues emerged strongly as did the mediating factors such as relations with specific health staff and a social support structure. A combination intervention addressing structural, social and psychological barriers could have an impact even in the precarious policy environment where this study was conducted.
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Affiliation(s)
- Rachel King
- Global Health Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Zubayiri Sebyala
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Moses Ogwal
- School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - George Aluzimbi
- Centers for Disease Control and Prevention, Uganda, Kampala, Uganda
| | - Rose Apondi
- Centers for Disease Control and Prevention, Uganda, Kampala, Uganda
| | - Steven Reynolds
- Department of Medicare, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- National Institute of Allergy and Infectious Diseases Division of Intramural Research, Bethesda, Maryland, USA
| | - Patrick Sullivan
- Department of Epidemiology, Rollins School of Public Health, Atlanta, Georgia, USA
| | - Wolfgang Hladik
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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16
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Topp SM, Chetty-Makkan CM, Smith HJ, Chimoyi L, Hoffmann CJ, Fielding K, Reid SE, Olivier AJ, Hausler H, Herce ME, Charalambous S. "It's Not Like Taking Chocolates": Factors Influencing the Feasibility and Sustainability of Universal Test and Treat in Correctional Health Systems in Zambia and South Africa. GLOBAL HEALTH: SCIENCE AND PRACTICE 2019; 7:189-202. [PMID: 31249019 PMCID: PMC6641809 DOI: 10.9745/ghsp-d-19-00051] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/09/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sub-Saharan African correctional facilities concentrate large numbers of people who are living with HIV or at risk for HIV infection. Universal test and treat (UTT) is widely recognized as a promising approach to improve the health of individuals and a population health strategy to reduce new HIV infections. In this study, we explored the feasibility and sustainability of implementing UTT in correctional facilities in Zambia and South Africa. METHODS Nested within a UTT implementation research study, our qualitative evaluation of feasibility and sustainability used a case-comparison design based on data from 1 Zambian and 3 South African correctional facilities. Primary data from in-depth interviews with incarcerated individuals, correctional managers, health care providers, and policy makers were supplemented by public policy documents, study documentation, and implementation memos in both countries. Thematic analysis was informed by an empirically established conceptual framework for health system analysis. RESULTS Despite different institutional profiles, we were able to successfully introduce UTT in the South Africa and Zambian correctional facilities participating in the study. A supportive policy backdrop was important to UTT implementation and establishment in both countries. However, sustainability of UTT, defined as relevant government departments' capacity to independently plan, resource, and administer quality UTT, differed. South Africa's correctional facilities had existing systems to deliver and monitor chronic HIV care and treatment, forming a "scaffolding" for sustained UTT despite some human resources shortages and poorly integrated health information systems. Notwithstanding recent improvements, Zambia's correctional health system demonstrated insufficient material and technical capacity to independently deliver quality UTT. In the correctional facilities of both countries, inmate population dynamics and their impact on HIV-related stigma were important factors in UTT service uptake. CONCLUSION Findings demonstrate the critical role of policy directives, health service delivery systems, adequate resourcing, and population dynamics on the feasibility and likely sustainability of UTT in corrections in Zambia and South Africa.
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Affiliation(s)
- Stephanie M Topp
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Queensland, Australia. .,Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | - Helene J Smith
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia
| | | | | | | | - Stewart E Reid
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,Division of Infectious Diseases, Department of Medicine, University of Alabama at Birmingham, School of Medicine, Birmingham, AL, USA
| | | | | | - Michael E Herce
- Centre for Infectious Disease Research in Zambia (CIDRZ), Lusaka, Zambia.,Institute for Global Health & Infectious Diseases, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Salome Charalambous
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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