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Chinogurei C, Manne-Goehler J, Kahn K, Kabudula CW, Cornell M, Rohr JK. Socio-Behavioural Barriers to Viral Suppression in the Older Adult Population in Rural South Africa. AIDS Behav 2024; 28:2307-2313. [PMID: 38619653 PMCID: PMC11199210 DOI: 10.1007/s10461-024-04328-9] [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: 03/20/2024] [Indexed: 04/16/2024]
Abstract
South Africa has the largest share of people living with HIV in the world and this population is ageing. The social context in which people seek HIV care is often ignored. Apart from clinical interventions, socio-behavioural factors impact successful HIV care outcomes for older adults living with HIV. We use cross-sectional data linked with demographic household surveillance data, consisting of HIV positive adults aged above 40, to identify socio-behavioural predictors of a detectable viral load. Older adults were more likely to have a detectable viral load if they did not disclose their HIV positive status to close family members (aOR 2.56, 95% CI 1.89-3.46), resided in the poorest households (aOR 1.98, 95% CI 1.23-3.18), or were not taking medications other than ART (aOR 1.83, 95% CI 1.02-1.99) likely to have a detectable. Clinical interventions in HIV care must be supported by understanding the socio-behavioural barriers that occur outside the health facility. The importance of community health care workers in bridging this gap may offer more optimum outcomes for older adults ageing with HIV.
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Affiliation(s)
- Chido Chinogurei
- Centre of Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, Cape Town, South Africa.
| | - J Manne-Goehler
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - K Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - C W Kabudula
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - M Cornell
- Centre of Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - J K Rohr
- Center for Population and Development Studies, Harvard University, Cambridge, MA, USA
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Wanjala SW, Nyongesa MK, Mapenzi R, Luchters S, Abubakar A. A qualitative inquiry of experiences of HIV-related stigma and its effects among people living with HIV on treatment in rural Kilifi, Kenya. Front Public Health 2023; 11:1188446. [PMID: 37427260 PMCID: PMC10324964 DOI: 10.3389/fpubh.2023.1188446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 05/25/2023] [Indexed: 07/11/2023] Open
Abstract
Background The pervasiveness of HIV-related stigma and discrimination, and its consequences on HIV prevention and treatment, have been well documented. However, little is known about the lived experiences of HIV-related stigma and its effects among the general adult population living with HIV in rural African settings. This study set out to explore this knowledge gap. Methods From April to June 2018, we conducted in-depth interviews with a convenience sample of 40 adults living with HIV aged 18-58 years in Kilifi, Kenya. A semi-structured interview guide was used to explore experiences of HIV-related stigma and its impact on these adults. A framework approach was used to analyze the data using NVIVO 11 software. Results Participants reported experiences of HIV-related stigma in its various forms (anticipated, perceived, internalised, and enacted), as well as its effects on HIV treatment and social and personal spheres. The internalisation of stigma caused by enacted stigma impacted care-seeking behavior resulting in worse overall health. Anxiety and depression characterized by suicidal ideation were the results of internalised stigma. Anticipated stigma prompted HIV medication concealment, care-seeking in remote healthcare facilities, and care avoidance. Fewer social interactions and marital conflicts resulted from perceived stigma. Overall, HIV-related stigma resulted in partial and non-disclosure of HIV seropositivity and medication non-adherence. At a personal level, mental health issues and diminished sexual or marital prospects (for the unmarried) were reported. Conclusion Despite high awareness of HIV and AIDS among the general population in Kenya, adults living with HIV in rural Kilifi still experience different forms of HIV-related stigma (including self-stigma) that result in a raft of social, personal, and HIV-treatment-related consequences. Our findings underscore the urgent need to reevaluate and adopt more effective strategies for implementing HIV-related anti-stigma programs at the community level. Addressing individual-level stigma will require the design of targeted interventions. To improve the lives of adults living with HIV in Kilifi, the effects of HIV-related stigma, particularly on HIV treatment, must be addressed.
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Affiliation(s)
- Stanley W. Wanjala
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Department of Social Sciences, School of Humanities and Social Sciences, Pwani University, Kilifi, Kenya
| | - Moses K. Nyongesa
- Neuroassessment Group, KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
- Department of Clinical, Neuro- and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
| | - Rachael Mapenzi
- Neuroassessment Group, KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
| | - Stanley Luchters
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
- Centre for Sexual Health and HIV AIDS Research (CeSHHAR), Harare, Zimbabwe
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Amina Abubakar
- Neuroassessment Group, KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), Kilifi, Kenya
- Institute for Human Development, Aga Khan University, Nairobi, Kenya
- Department of Public Health, School of Human and Health Sciences, Pwani University, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
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Dhaor SS. Lived Experiences of Internalized Stigma Among HIV-Positive Adults in Delhi, India. COMMUNITY HEALTH EQUITY RESEARCH & POLICY 2023; 43:301-309. [PMID: 34107807 DOI: 10.1177/0272684x211022580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The HIV infection is deeply associated with fear, stigma, discrimination, and internalization of the stigma. The ignorance around modes of transmission has led to many myths and misconceptions surrounding the infection. There is a stigma of contagion, along with the stigma of morality. Being ill and facing death is a situation that affects day to day living of the infected. It is not the virus but the stigmatizing environment around the infected that makes life with the virus a difficult journey. The infection leads to many behavioral issues and challenges for the infected as well as affected. In a mixed-method research, 105 HIV-positive consenting adults were recruited through the snowball method. They were interviewed using a semi-structured interview schedule in a confidential environment. Focus group discussions were conducted with infected males, females, men having sex with men (MSM), and uninfected partners of the infected respondents to understand the interpersonal issues and challenges. The current research explores and describes the impact of HIV and resultant internalized stigma upon the life of the infected in the background of moralistic values governing sexual behavior.
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Paiboon N, Songtaweesin WN, Wongharn P, Moonwong J, Khamthi S, Premgamone A, Theerawit T, Saisaengjan C, Kawichai S, Anugulruengkitt S, Puthanakit T. Social Network Strategy to Promote HIV Testing and Linkage to HIV Services among Young men who Have sex with men and Transgender Women in Thailand. J Int Assoc Provid AIDS Care 2022; 21:23259582221143672. [PMID: 36464688 PMCID: PMC9726844 DOI: 10.1177/23259582221143672] [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] [Indexed: 12/07/2022] Open
Abstract
Background: Social network strategies (SNS) assumes that people in the same social share similar HIV risk. Methods: This study evaluated SNS to promote HIV testing of young men who have sex with men (YMSM) and transgender women (YTGW) aged 15-24 years. "Recruiters" referred their 'network members' (NMs) to clinic. NMs were provided HIV testing. Proportions of first-time HIV testers and number of NMs were analyzed. Results: Between April 2021 to March 2022, 83 recruiters referred 202 NMs. Median age of NMs was 19 years (IQR 17-20), 62% were YMSM. One-hundred-and-twenty-four NMs (61%) were first-time HIV testers. YTGW recruited more NMs per recruiter (5.4 vs 1.4, p = 0.002). HIV prevalence was 3.0% (95% CI 1.1-6.4). Thirty-one-point-three percent of NMs at HIV risk initiated oral HIV preexposure prophylaxis. Conclusions: SNS is a good strategy to reach adolescents at risk of HIV infection. More than half of NMs were first-time HIV testers.
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Affiliation(s)
- Nantika Paiboon
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Wipaporn Natalie Songtaweesin
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Prissana Wongharn
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Jutamanee Moonwong
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Sasiprapha Khamthi
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Athiporn Premgamone
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Tuangtip Theerawit
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Chutima Saisaengjan
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Surinda Kawichai
- Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Suvaporn Anugulruengkitt
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand
| | - Thanyawee Puthanakit
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand,Center of Excellence for Pediatric Infectious Diseases and Vaccines, Chulalongkorn University, Bangkok, Thailand,Thanyawee Puthanakit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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Paul AM, Lee C, Fesshaye B, Gur-Arie R, Zavala E, Singh P, Karron RA, Limaye RJ. Conceptualizing the COVID-19 Pandemic: Perspectives of Pregnant and Lactating Women, Male Community Members, and Health Workers in Kenya. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10784. [PMID: 36078503 PMCID: PMC9518350 DOI: 10.3390/ijerph191710784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 06/15/2023]
Abstract
Pregnant women are at greater risk of adverse outcomes from SARS-CoV-2 infection. There are several factors which can influence the ways in which pregnant women perceive COVID-19 disease and behaviorally respond to the pandemic. This study seeks to understand how three key audiences-pregnant and lactating women (PLW), male community members, and health workers-in Kenya conceptualize COVID-19 to better understand determinants of COVID-19 related behaviors. This study used qualitative methods to conduct 84 in-depth interviews in three counties in Kenya. Data were analyzed using a grounded theory approach. Emerging themes were organized based on common behavioral constructs thought to influence COVID-19 related behaviors and included myths, risk perception, economic implications, stigma, and self-efficacy. Results suggest that risk perception and behavioral attitudes substantially influence the experiences of PLW, male community members, and health workers in Kenya during the COVID-19 pandemic. Public health prevention and communication responses targeting these groups should address potential barriers to preventive health behaviors, such as the spread of misinformation, financial constraints, and fear of social ostracization.
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Affiliation(s)
- Alicia M. Paul
- International Vaccine Access Center, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Clarice Lee
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Berhaun Fesshaye
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Rachel Gur-Arie
- Berman Institute of Bioethics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Eleonor Zavala
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Prachi Singh
- International Vaccine Access Center, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Ruth A. Karron
- Center for Immunization Research, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Rupali J. Limaye
- International Vaccine Access Center, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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Olaseni AO, Olley BO. Experimenting the Effect of Psychological Inoculation as Intervention to Enhanced Self-Disclosure Outcomes Among Recently Diagnosed People Living with HIV. BASIC AND APPLIED SOCIAL PSYCHOLOGY 2022. [DOI: 10.1080/01973533.2022.2090840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Wang Q, Fong VWI, Qin Q, Yao H, Zheng J, Wang X, Wang A, Gao Q, Mo PKH. Trends in the psychosocial and mental health of HIV-positive women in China from 2015 to 2020: Results from two cross-sectional surveys. Health Expect 2022; 25:1555-1562. [PMID: 35726358 PMCID: PMC9327813 DOI: 10.1111/hex.13498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 11/05/2022] Open
Abstract
Background The human immunodeficiency virus (HIV) continues to be one of the major public health challenges in the world. Despite the advancement in medication and changes in views towards HIV in Chinese society, little is known about the changes in the psychosocial and mental health of HIV‐positive women in recent years. Objectives The present study examined the change in depression, anxiety, stigma, relationship with the child, intimacy with a partner, and social support from family, friends, and health professionals, for HIV‐positive women in China from 2015 to 2020. Methods Two cross‐sectional surveys were conducted in 2015 and 2020, and 429 and 382 HIV‐positive women were recruited from the Women's Health Department in Yunnan and Guangxi, China between November 2015 to May 2016, and November 2019 to January 2020, respectively. Results After controlling for significant sociodemographic variables, participants recruited in 2019–2020 had significantly lower levels of depression and anxiety and higher scores on emotional and tangible support from friends. On the other hand, they had lower scores in intimacy with partners and emotional and tangible support from family. No significant changes were found in stigma, relationship with the child, and support from health professionals. Conclusion Results provide important information on the changes in psychosocial and mental health, which offer insights into the design of interventions to promote psychosocial and mental health among HIV‐positive women in China. Patient or Public Contribution HIV‐positive women contributed to the data of this study. Health care professionals were involved in the discussion of the methods and results.
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Affiliation(s)
- Qian Wang
- Antenatal Health Care Department, National Center for Women and Children's Health, China CDC, Beijing, China
| | - Vivian W I Fong
- School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Qinghua Qin
- Antenatal Health Care Department, Maternal and Child Health Hospital of Guangxi, Zhuang Autonomous Region, Nanning, China
| | - Hui Yao
- Antenatal Health Care Department, Maternal and Child Health Hospital of Guangxi, Zhuang Autonomous Region, Nanning, China
| | - Jiarui Zheng
- Antenatal Health Care Department, Yunnan Maternal and Child Health Care Hospital, Kunming, China
| | - Xiaoyan Wang
- Antenatal Health Care Department, National Center for Women and Children's Health, China CDC, Beijing, China
| | - Ailing Wang
- Antenatal Health Care Department, National Center for Women and Children's Health, China CDC, Beijing, China
| | - Qun Gao
- Antenatal Health Care Department, National Center for Women and Children's Health, China CDC, Beijing, China
| | - Phoenix K H Mo
- School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin, Hong Kong.,The Chinese University of Hong Kong Shenzhen Research Institute, Shenzhen, China
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dela Cruz AM, Maposa S, Patten S, Abdulmalik I, Magagula P, Mapfumo S, Abate TD, Carter A, Spies P, Harrowing J, Hall M, Afzal AR, Caine V. “I die silently inside”. Qualitative findings from a Study of People living with HIV who Migrate to and Settle in Canada. J Migr Health 2022; 5:100088. [PMID: 35341065 PMCID: PMC8941335 DOI: 10.1016/j.jmh.2022.100088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 12/02/2022] Open
Abstract
This study presents compelling accounts of African, Caribbean, and black (ACB) 2 immigrants who feel excluded, isolated, and distanced by others because of their positive 3 HIV status. 4. Among ACB immigration applicants living with HIV in Canada, a positive HIV status 5 had significant consequences on a person's ability to access health and social care, stable 6 housing, meaningful employment, as well as movement within society. 7. It is important to understand the experiences of racialized immigration applicants and 8 HIV screening processes during immigration from an intersectionality lens. 9. Health and social care providers of ACB immigrants living with HIV must consider the 10 interaction of race, legal status, institutional laws and structures, gender, culture, trauma, 11 and intergenerational contexts in providing adequate and appropriate health and social 12 care to this population.
We report on qualitative findings from a mixed methods study, examining enacted and internalized stigma during mandatory HIV screening among immigration applicants living with HIV in Canada. Qualitative findings show alignment with characteristics of internalized HIV stigma. We conducted 34 semi-structured interviews, and analyzed the data through thematic analysis, using Intersectionality and the Internalized HIV Stigma Scale as our theoretical and analytical frameworks. Participants described experiences of enacted and internalized HIV stigma in ways that were consistent with the four main domains of stereotypes, disclosure concerns, social relationships, and self-acceptance, but also extended the description of HIV stigma beyond these domains. Experiences of internalized HIV stigma and enacted stigma during the Canadian Immigration Medical Examination could potentially influence individuals’ long-term engagement in the HIV care cascade during the process of migration to, and settlement in, Canada. We present recommendations for the broader migrant health research agenda, health and social care providers, and public health policies.
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Affiliation(s)
- Aniela M. dela Cruz
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
- Corresponding author.
| | - Sithokozile Maposa
- College of Nursing, University of Saskatchewan, Prince Albert, Saskatchewan, Canada
| | - San Patten
- San Patten and Associates, Halifax, Nova Scotia, Canada
| | - Inusa Abdulmalik
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | | | | | - Jean Harrowing
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Marc Hall
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Arfan R. Afzal
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
| | - Vera Caine
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Abstract
As interlocutors in national level discourse with the power to influence public opinion and inform policy, the news media are an important data source in understanding the constitutive roles played by culture and discourse in shaping health experiences and outcomes. This paper reports on a critical discourse analysis of news media coverage of HIV in the Republic of Ireland between 2006 and 2016. This period is significant because of the considerable increase in new HIV diagnoses that occurred in Ireland after the 2008 recession. Analysis of articles (n = 103) demonstrated a pattern of dividing practices whereby people living with or affected by HIV were frequently positioned as somatically and morally deficient via discourses of risk and responsibility. Little focus was given over to examination of the structural drivers of HIV, occluding the social context of the epidemic. The findings suggest that media discourses on HIV have the potential to other people living with HIV and generate stigma by invoking a dynamic of blame and shame frequently implicated in the stigma process.
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Ismail R, Voss JG, Yona S, Nurachmah E, Boutain D, Lowe C, John-Stewart G, Woods NF. Classifying stigma experience of women living with HIV in Indonesia through the social ecological model. Health Care Women Int 2021; 43:345-366. [PMID: 34379051 DOI: 10.1080/07399332.2021.1929989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Little is known how stigma theories apply to women living with HIV (WLWH). To apply stigma theories to WLWH, and locate within the dimensions of the Social-Ecological Model (SEM). Using a literature review and a theoretical subtraction to apply stigma forms to the SEM dimensions. WLWH begin to self-stigmatize, receive stigma based on fear from the family and community. Healthcare providers and society stigmatize WLWH by ascribing character flaws to them. The SEM allowed us to locate the dimensions of stigma and identify areas for future interventions for WLWH in Indonesia and other countries.
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Affiliation(s)
- Rita Ismail
- Ministry of Health Republic of Indonesia, Jakarta, Indonesia
| | - Joachim G Voss
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sri Yona
- Department of Medical Surgical Nursing, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - Elly Nurachmah
- Department of Medical Surgical Nursing, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | - Doris Boutain
- Psychosocial and Community Health, School of Nursing, University of Washington, Seattle, Washington, USA
| | - Celia Lowe
- Department of Anthropology, University of Washington, Seattle, Washington, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Nancy Fugate Woods
- Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle, Washington, USA
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Akatukwasa C, Getahun M, El Ayadi AM, Namanya J, Maeri I, Itiakorit H, Owino L, Sanyu N, Kabami J, Ssemmondo E, Sang N, Kwarisiima D, Petersen ML, Charlebois ED, Chamie G, Clark TD, Cohen CR, Kamya MR, Bukusi EA, Havlir DV, Camlin CS. Dimensions of HIV-related stigma in rural communities in Kenya and Uganda at the start of a large HIV 'test and treat' trial. PLoS One 2021; 16:e0249462. [PMID: 33999961 PMCID: PMC8128261 DOI: 10.1371/journal.pone.0249462] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 03/18/2021] [Indexed: 11/19/2022] Open
Abstract
HIV-related stigma is a frequently cited barrier to HIV testing and care engagement. A nuanced understanding of HIV-related stigma is critical for developing stigma-reduction interventions to optimize HIV-related outcomes. This qualitative study documented HIV-related stigma across eight communities in east Africa during the baseline year of a large HIV test-and-treat trial (SEARCH, NCT: 01864603), prior to implementation of widespread community HIV testing campaigns and efforts to link individuals with HIV to care and treatment. Findings revealed experiences of enacted, internalized and anticipated stigma that were highly gendered, and more pronounced in communities with lower HIV prevalence; women, overwhelmingly, both held and were targets of stigmatizing attitudes about HIV. Past experiences with enacted stigma included acts of segregation, verbal discrimination, physical violence, humiliation and rejection. Narratives among women, in particular, revealed acute internalized stigma including feelings of worthlessness, shame, embarrassment, and these resulted in anxiety and depression, including suicidality among a small number of women. Anticipated stigma included fears of marital dissolution, verbal and physical abuse, gossip and public ridicule. Anticipated stigma was especially salient for women who held internalized stigma and who had experienced enacted stigma from their partners. Anticipated stigma led to care avoidance, care-seeking at remote facilities, and hiding of HIV medications. Interventions aimed at reducing individual and community-level forms of stigma may be needed to improve the lives of PLHIV and fully realize the promise of test-and-treat strategies.
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Affiliation(s)
| | - Monica Getahun
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Alison M. El Ayadi
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Judith Namanya
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Irene Maeri
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Lawrence Owino
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Naomi Sanyu
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jane Kabami
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Norton Sang
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Maya L. Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, CA, United States of America
| | - Edwin D. Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, United States of America
| | - Gabriel Chamie
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Tamara D. Clark
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Craig R. Cohen
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration, Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Elizabeth A. Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Diane V. Havlir
- Division of HIV, Infectious Disease and Global Medicine, Department of Medicine, University of California, San Francisco, CA, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Bixby Center for Global Reproductive Health, Gynecology & Reproductive Sciences, University of California, San Francisco, CA, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, CA, United States of America
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Moussa AB, Delabre RM, Villes V, Elkhammas M, Bennani A, Ouarsas L, Filali H, Alami K, Karkouri M, Castro DR. Determinants and effects or consequences of internal HIV-related stigma among people living with HIV in Morocco. BMC Public Health 2021; 21:163. [PMID: 33468093 PMCID: PMC7815182 DOI: 10.1186/s12889-021-10204-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 01/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV-related stigma and discrimination constitute a barrier to different intervention programs. Unlike external stigma, internal stigma is not well explored in in the Middle East and North African countries, while grasping this particular form of stigma is essential to limit its effects. The present study aims to measure internal stigma effects and to identify factors associated with this kind of stigma not yet documented among people living with HIV (PLHIV) in Morocco. METHODS The PLHIV Stigma Index questionnaire (adapted and translated into French and Moroccan Arabic dialect "darija") was used to collect information regarding the stigma and discrimination experienced by PLHIV across 8 cities in Morocco (September-October 2016). A randomly drawn cluster of 10 PLHIV, consisting of 5 men and 5 women, was drawn at each participating medical care center to achieve a nationally representative sample of PLHIV. Fifteen interviewers living with HIV and five supervisors were selected and trained to administer the questionnaire. An internal stigma score (range: 0-7), was calculated based on seven negative feelings/ beliefs. Negative binomial regression was used to identify characteristics associated with the internal stigma score. RESULTS Among 626 PLHIV, internal stigma was reported by 88.2%. The median [IQR] internal stigma score was 4 [2-5]. Regarding internal stigma, 51% avoided going to the local clinic when needed and 44% chose not to attend social gatherings. Belonging to at least one key population (aIRR [95%CI] = 1.15 [1.03; 1.28]), experiencing discriminatory reactions from family following HIV status disclosure (1.28 [1.11; 1.49]), avoiding HIV services for fear of stigmatization by staff (1.16 [1.05; 1.28]) and being denied health services because of HIV status (1.16 [1.03;1.32]), are among the factors significantly associated with an increase of the internal stigma score. CONCLUSIONS Internal stigma is high among Moroccan PLHIV and significantly impacting their life decisions and their healthcare access. Multi-level interventions are needed to address internal stigma experienced by PLHIV in Morocco.
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Affiliation(s)
- Amal Ben Moussa
- Association de Lutte Contre le Sida, Casablanca, Morocco. .,Community-based Research Laboratory, Coalition PLUS, Pantin, France.
| | | | - Virginie Villes
- Community-based Research Laboratory, Coalition PLUS, Pantin, France
| | | | - Aziza Bennani
- Programme National de Lutte Contre le Sida, Ministère de la Santé, Rabat, Morocco
| | - Lahoucine Ouarsas
- Association de Lutte Contre le Sida, Casablanca, Morocco.,Community-based Research Laboratory, Coalition PLUS, Pantin, France
| | - Hind Filali
- Ecole Nationale de Santé Publique, Rabat, Morocco
| | | | - Mehdi Karkouri
- Association de Lutte Contre le Sida, Casablanca, Morocco.,Community-based Research Laboratory, Coalition PLUS, Pantin, France
| | - Daniela Rojas Castro
- Community-based Research Laboratory, Coalition PLUS, Pantin, France.,Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
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13
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Adane B, Yalew M, Damtie Y, Kefale B. Perceived Stigma and Associated Factors Among People Living with HIV Attending ART Clinics in Public Health Facilities of Dessie City, Ethiopia. HIV AIDS-RESEARCH AND PALLIATIVE CARE 2020; 12:551-557. [PMID: 33116917 PMCID: PMC7549310 DOI: 10.2147/hiv.s274019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/09/2020] [Indexed: 11/23/2022]
Abstract
Introduction Despite the fact that responses to epidemics of human immune-deficiency virus (HIV) have gradually improved; it remains one of the world's public health challenges, particularly in low- and middle-income countries. Evidence is still limited in this area and this study aimed to assess the magnitude of perceived stigma and associated factors among people living with HIV (PLWH) in public health facilities of Dessie city, Ethiopia. Methods A health facility-based cross-sectional study was conducted among a total of 422 PLWH from September 1 to October 30, 2019 in Dessie city. A pretested structured interviewer-administered questionnaire was used to collect the data and it was analyzed using Stata/SE 14. Multivariable binary logistic regression analysis was used to identify factors associated with perceived stigma. The adjusted odds ratio (AOR) along with 95% confidence interval (CI) was estimated to measure the strength and direction of the association. Statistical significance was declared at P value less than 0.05. Results The overall magnitude of perceived stigma among people living with HIV in public health facilities of Dessie city was 41.93% [95% CI: (37.25, 46.75)]. Perceived stigma was positively associated with being female [AOR=2.08, 95% CI: (1.26, 3.46)], living in rural areas [AOR=1.80, 95% CI: (1.10, 2.94)] and not disclosing HIV status [AOR=2.36, 95% CI: (1.19, 4.66)]. Conclusion In this study, the magnitude of perceived stigma was high as compared to UNAIDS standard, and sex, place of residence, and disclosure of HIV serostatus were significantly associated with perceived stigma. The findings suggested that special emphasis should be placed on rural residents in order to reduce perceived stigma. Moreover, counseling should focus on disclosing HIV serostatus to anyone else interested to disclose particularly for females.
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Affiliation(s)
- Bezawit Adane
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Melaku Yalew
- Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Yitayish Damtie
- Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Bereket Kefale
- Department of Reproductive and Family Health, School of Public Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
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14
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Abstract
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.
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15
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Ramlagan S, Sifunda S, Peltzer K, Jean J, Ruiter RA. Correlates of perceived HIV-related stigma among HIV-positive pregnant women in rural Mpumalanga province, South Africa. JOURNAL OF PSYCHOLOGY IN AFRICA 2019. [DOI: 10.1080/14330237.2019.1603022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Shandir Ramlagan
- HIV/Aids, STI and TB Unit, Human Sciences Research Council, Pretoria, South Africa
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Sibusiso Sifunda
- HIV/Aids, STI and TB Unit, Human Sciences Research Council, Pretoria, South Africa
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
| | - Karl Peltzer
- HIV/Aids, STI and TB Unit, Human Sciences Research Council, Pretoria, South Africa
- Department of Research and Innovation, University of Limpopo, Sovenga, South Africa
| | - Jenny Jean
- Miller School of Medicine, University of Miami, Miami, USA
| | - Robert A.C. Ruiter
- Department of Work and Social Psychology, Maastricht University, Maastricht, The Netherlands
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16
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Letshwenyo-Maruatona SB, Madisa M, Boitshwarelo T, George-Kefilwe B, Kingori C, Ice G, Bianco JA, Marape M, Haile ZT. Association between HIV/AIDS knowledge and stigma towards people living with HIV/AIDS in Botswana. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2019; 18:58-64. [PMID: 30880585 DOI: 10.2989/16085906.2018.1552879] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In Botswana, an estimated 350 000 people live with HIV/AIDS. HIV/AIDS testing rates are low, suggesting that many other people remain undiagnosed. Stigma related to HIV/AIDS is prevalent and contributes to low testing rates and under-diagnosis of the virus. Identifying factors that contribute to stigma, such as insufficient or inaccurate knowledge of HIV/AIDS, may be critical in increasing early identification and treatment. This cross-sectional study used nationally representative data from the 2013 Botswana AIDS Impact Survey (BAIS) IV to examine the relationship between HIV/AIDS knowledge and stigmatising attitudes toward people living with HIV/AIDS (PLWHA). The mean (standard error) for stigma towards PLWHA score and HIV/AIDS knowledge score were 0.99 (0.02) and 5.90 (0.03) respectively. HIV/AIDS knowledge score and stigma towards PLWHA score were strongly positively correlated r (4,4045) = 0.415, p < 0.001). After adjusting for potential confounders, HIV/AIDS knowledge score significantly predicted stigma towards PLWHA score [coefficient β (95% CI)] [-0.25 (-0.29, -0.20), p < 0.001]. These findings imply that programmes and interventions that increase HIV/AIDS knowledge may reduce the pervasive apprehension, blame, and stigmatising attitude held towards PLWHA in Botswana.
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Affiliation(s)
| | | | | | | | - Caroline Kingori
- c Department of Social and Public Health , Ohio University , Athens , Ohio , USA
| | - Gillian Ice
- d Department of Social Medicine, Heritage College of Osteopathic Medicine and College of Health Sciences and Professions , Ohio University , Athens , Ohio , USA
| | - Joseph A Bianco
- e Department of Social Medicine , Ohio University Heritage College of Osteopathic Medicine , Athens , Ohio , USA
| | - Marape Marape
- f Marape & Marape Family Medical and Public Health Clinic , Gaborone , Botswana
| | - Zelalem T Haile
- g Department of Social Medicine, Heritage College of Osteopathic Medicine , Ohio University , Dublin , Ohio , USA
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17
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Brennan-Ing M. Diversity, stigma, and social integration among older adults with HIV. Eur Geriatr Med 2019; 10:239-246. [PMID: 34652745 DOI: 10.1007/s41999-018-0142-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 11/24/2018] [Indexed: 11/25/2022]
Abstract
The population of people with HIV is aging globally as access to anti-retroviral therapy becomes more widely available. The diversity of older population with HIV has an impact on their experiences of stigma. HIV stigma may be enacted or felt. Enacted stigma is the prejudice, discrimination, and mistreatment that individuals and societies use to sanction people with HIV. Felt stigma refers to the internalized feelings of shame, guilt, and fear that arise from enacted stigma. Nondisclosure is rooted in the fear of negative consequences of revealing one's HIV status, such as losing a job, or being rejected by one's social network. Stigma may also affect social integration through self-protective withdrawal to avoid anticipated stigma. In addition to facing HIV stigma, people with HIV may possess multiple discredited identities due to their race, ethnicity, gender identity, etc., which is described as intersectionality. Older age represents an additional intersectional identity that affects people with HIV through the experience of ageism. Stigma and discrimination from HIV or any discredited identity are linked to poorer physical and mental health outcomes. Given the pervasiveness of stigma, it is not surprising that many older adults with HIV are socially isolated and report greater self-perceived stigma compared to those who are more socially integrated. While there is evidence that HIV stigma has declined compared to previous eras, more research is needed on HIV stigma among older adults in low- and middle-income countries to design policies and programs to combat HIV stigma globally.
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Affiliation(s)
- Mark Brennan-Ing
- Brookdale Center for Healthy Aging, Hunter College, The City University of New York, 2180 Third Avenue, Room 814, New York, NY, 10035, USA.
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18
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Zhou E, Qiao Z, Cheng Y, Zhou J, Wang W, Zhao M, Qiu X, Wang L, Song X, Zhao E, Wang R, Zhao X, Yang Y, Yang X. Factors associated with depression among HIV/AIDS children in China. Int J Ment Health Syst 2019; 13:10. [PMID: 30828360 PMCID: PMC6381654 DOI: 10.1186/s13033-019-0263-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 01/22/2019] [Indexed: 02/05/2023] Open
Abstract
Background Depression in HIV/AIDS children not only worsens the progression and outcome of illness, but also impacts their quality of life, having a negative influence on society. The present study was conducted from a psychosocial perspective, considering children’s social desirability, cognitive emotion regulation, and perceived social support to identify the factors influencing depression in HIV-infected children in China. Methods Participants were 155 children aged 8–18 years who were eligible to participate in this study assessing depression and associated risk factors using the Children’s Depression Inventory, Cognitive Emotion Regulation Questionnaire, Multidimensional Scale of Perceived Social Support, and Children’s Social Desirability scale. Hierarchical linear regression analysis was conducted to model the effects of social desirability, perceived social support, and cognitive emotion regulation on depression in HIV/AIDS children. Results Statistically significant linear relationships were found among social desirability, perceived social support, partial dimensions of cognitive emotion regulation, and children’s depression scores. Perceived social support, planning and positive reappraisal were negatively related to the depression. Conversely, social desirability, catastrophizing and other-blame were positively associated with the depression. Linear regression analysis indicated that children’s social desirability, perceived social support, and one dimension of cognitive emotion regulation (catastrophizing) were found to significantly predict depression. Conclusions Psychosocial factors have an important influence on the depression experienced by HIV-infected children. Interventions from personal subjective psychosocial to reduce depression in HIV-infected children in China are warranted.
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Affiliation(s)
- Enpeng Zhou
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Zhengxue Qiao
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Yuewu Cheng
- Shangcai Center for Disease Control and Prevention, Zhumadian, Henan China
| | - Jiawei Zhou
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Wenbo Wang
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Mingzhe Zhao
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Xiaohui Qiu
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Lin Wang
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Xuejia Song
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Erying Zhao
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Ruopeng Wang
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Xueyan Zhao
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Yanjie Yang
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
| | - Xiuxian Yang
- 1Psychology Department of the Public Health Institute of Harbin Medical University, No. 157, Baojian Road, Nangang District, Harbin, 150081 Heilongjiang Province China
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A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries. BMC Med 2019; 17:17. [PMID: 30764819 PMCID: PMC6376728 DOI: 10.1186/s12916-019-1250-8] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 01/02/2019] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions. METHODS We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations. RESULTS Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes. CONCLUSIONS Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.
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Prasitsuebsai W, Sethaputra C, Lumbiganon P, Hansudewechakul R, Chokephaibulkit K, Truong KH, Nguyen LV, Mohd Razali KA, Nik Yusoff NK, Fong MS, Teeraananchai S, Ananworanich J, Durier N. Adherence to antiretroviral therapy, stigma and behavioral risk factors in HIV-infected adolescents in Asia. AIDS Care 2018; 30:727-733. [PMID: 29336591 DOI: 10.1080/09540121.2018.1425363] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We studied behavioral risks among HIV-infected and uninfected adolescents using an audio computer-assisted self-interview. A prospective cohort study was initiated between 2013 and 2014 in Malaysia, Thailand, and Vietnam. HIV-infected adolescents were matched to uninfected adolescents (4:1) by sex and age group (12-14 and 15-18 years). We enrolled 250 HIV-infected (48% male; median age 14.5 years; 93% perinatally infected) and 59 uninfected (51% male; median age 14.1 years) adolescents. At enrollment, HIV-infected adolescents were on antiretroviral therapy (ART) for a median (IQR) of 7.5 (4.7-10.2) years, and 14% had HIV-RNA >1000 copies/mL; 19% reported adherence <80%. Eighty-four (34%) HIV-infected and 26 (44%) uninfected adolescents reported having ever smoked cigarettes or drunk alcohol (p = 0.13); 10% of HIV-infected and 17% of uninfected adolescents reported having initiated sexual activity; 6 of the HIV-infected adolescents had HIV-RNA >1000 copies/mL. Risk behaviors were common among adolescents, with few differences between those with and without HIV.
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Affiliation(s)
- Wasana Prasitsuebsai
- a The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT) , The Thai Red Cross AIDS Research Centre , Bangkok , Thailand
| | | | - Pagakrong Lumbiganon
- c Faculty of Medicine , Srinagarind Hospital, Khon Kaen University , Khon Kaen , Thailand
| | | | | | | | | | | | | | | | - Sirinya Teeraananchai
- a The HIV Netherlands Australia Thailand Research Collaboration (HIV-NAT) , The Thai Red Cross AIDS Research Centre , Bangkok , Thailand
| | - Jintanat Ananworanich
- k US Military HIV Research Program , Walter Reed Army Institute of Research , Silver Spring , USA.,l Henry M. Jackson Foundation for the Advancement of Military Medicine , Bethesda , USA.,m SEARCH, The Thai Red Cross AIDS Research Centre , Bangkok , Thailand.,n University of Amsterdam , Amsterdam , the Netherlands
| | - Nicolas Durier
- b TREAT Asia/amfAR-The Foundation for AIDS Research , Bangkok , Thailand.,o Dreamlopments LTD , Bangkok , Thailand
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Kingori C, Nkansah MA, Haile Z, Darlington KA, Basta T. Factors Associated with HIV Related Stigma among College Students in the Midwest. AIMS Public Health 2017; 4:347-363. [PMID: 29546222 PMCID: PMC5690459 DOI: 10.3934/publichealth.2017.4.347] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/30/2017] [Indexed: 11/24/2022] Open
Abstract
In general, U.S. college students have low perceived susceptibility of acquiring HIV infection while 15–25 percent of youth have had negative perceptions towards HIV positive individuals. Factors associated with HIV stigma among college students were examined in a convenience sample of 200 students. Descriptive and inferential statistics were utilized to summarize the data. Only four percent of participants responded correctly to HIV transmission knowledge items. HIV transmission knowledge scores were significantly higher for participants who were single with partner and those who resided outside university residential dorms (p < 0.05). There was a significant negative correlation between composite HIV knowledge scores and stigma scores r = −0.18 (p < 0.05). After adjusting for confounders, a marginal significant negative linear relationship emerged (β = −0.09, p = 0.06) between HIV knowledge and stigma. HIV prevention education among college students needs to be addressed with nuance to minimize HIV knowledge gaps, stigma and student risk perception that impacts HIV prevention and stigma against those living with HIV.
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Affiliation(s)
- Caroline Kingori
- Department of Social and Public Health, Ohio University, Athens OH 45701
| | | | - Zelalem Haile
- Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University
| | | | - Tania Basta
- Department of Social and Public Health, Ohio University, Athens OH 45701
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Abstract
OBJECTIVE The aim of this study was to identify the range and frequency of patient-reported barriers and facilitators to antiretroviral treatment (ART) adherence in sub-Saharan Africa (SSA). DESIGN Studies from 2005 to 2016 were identified by searching 10 electronic databases and through additional hand and web-searching. METHODS Inclusion criteria were HIV-positive adults taking ART based in any SSA country, qualitative study or quantitative survey and included at least one patient-reported barrier or facilitator to ART adherence. Exclusion criteria were only including data from treatment-naive patients initiating ART, only single-dose treatment, participants residing outside of SSA and reviews. RESULTS After screening 11 283 records, 154 studies (161 papers) were included in this review. Forty-three barriers and 30 facilitators were reported across 24 SSA countries. The most frequently identified barriers across studies were forgetting (n = 76), lack of access to adequate food (n = 72), stigma and discrimination (n = 68), side effects (n = 67) and being outside the house or travelling (n = 60). The most frequently identified facilitators across studies were social support (n = 60), reminders (n = 55), feeling better or healthier after taking ART (n = 35), disclosing their HIV status (n = 26) and having a good relationship with a health provider (n = 22). CONCLUSION This review addresses the gap in knowledge by collating all the patient-reported barriers and facilitators to ART adherence in SSA. Current barriers measures need to be adapted or new tools developed to include the wide variety of factors identified. The factors that have the greatest impact need to be isolated so interventions are developed that reduce the barriers and enhance the facilitators.
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Kingori C, Haile ZT, Ngatia P, Nderitu R. Factors that can influence feelings towards and interactions with people living with HIV/AIDS in rural Central Kenya. Int J STD AIDS 2016; 28:910-919. [PMID: 27879430 DOI: 10.1177/0956462416680764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background In Kenya, HIV incidence and prevalence have declined. HIV rates are lower in rural areas than in urban areas. However, HIV infection is reported higher in men in rural areas (4.5%) compared to those in urban areas (3.7%). Objectives This study examined HIV knowledge, feelings, and interactions towards HIV-infected from 302 participants in rural Central Kenya. Methods Chi square tests and multivariable logistic regression analyzed variables of interest. Results Most participants exhibited positive feelings in their interaction with people living with HIV and AIDS (PLWHA). Association between HIV knowledge and socio-demographic characteristics revealed that the proportion of participants with a correct response differed by gender, age, level of education, and marital status ( p < 0.05). Compared to those with inadequate knowledge of HIV/AIDS, participants with adequate HIV/AIDS knowledge were nearly three times as likely to disagree that PLWHA should be legally separated from others to protect public health (adjusted odds ratio: aOR (95% CI) (2.76 (1.12, 6.80). Conclusions HIV stigma continues to impact HIV prevention strategies particularly in rural Central Kenya. Culturally, appropriate interventions addressing HIV knowledge among those with lower levels of education, single, older, and male are warranted. Review of HIV policies separating high-risk populations from the general population is needed to reduce stigma.
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Affiliation(s)
- Caroline Kingori
- 1 Department of Social and Public Health, Ohio University, Athens, OH, USA
| | - Zelalem T Haile
- 2 Department of Social Medicine, Heritage College of Osteopathic Medicine, Ohio University, Dublin, OH, USA
| | - Peter Ngatia
- 3 African Medical Research Foundation, Nairobi, Kenya
| | - Ruth Nderitu
- 4 Constituency AIDS Control Council, Othaya, Kenya
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Dimaggio G, Conti C, Lysaker PH, Popolo R, Salvatore G, Sofia SA. Reauthoring One's Own Life in the Face of Being HIV+: Promoting Healthier Narratives with Metacognitive Interpersonal Therapy. JOURNAL OF CONSTRUCTIVIST PSYCHOLOGY 2016. [DOI: 10.1080/10720537.2016.1238788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Caterina Conti
- Centro di Terapia Metacognitiva Interpersonale, Rome, Italy
| | - Paul H. Lysaker
- Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA, and Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Sonia A. Sofia
- Division of Infectious Disease, University of Catania, Italy
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25
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Li L, Lin C, Ji G. Gendered aspects of perceived and internalized HIV-related stigma in China. Women Health 2016; 57:1031-1043. [PMID: 27629916 DOI: 10.1080/03630242.2016.1235075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Although studies have demonstrated that females experience more HIV-related stigma than males do, questions remain regarding the different dimensions of the stigma (i.e., perceived versus internalized) in China. The present study investigated gender differences in perceived and internalized HIV-related stigma, taking into account the potential influence of education. The study was conducted between October 2011 and March 2013. A total of 522 people living with HIV (PLH) were recruited from Anhui Province, China. The PLH participated in a survey using the Computer Assisted Personal Interview (CAPI) method. The gender differences in perceived and internalized HIV-related stigma were calculated with and without stratifying by education level. Female participants had significantly less education than the male participants. No significant difference was observed between females and males with respect to perceived stigma. However, females reported significantly higher internalized stigma than males did (p < .001). When socio-demographic characteristics were controlled, the gender difference in internalized stigma remained significant among educated participants (p = .038). The findings suggested that gender differences in HIV-related stigma were primarily found for internalized stigma. Heightened intervention efforts are encouraged to reduce internalized HIV-related stigma, particularly among female PLH in China and other regions with similar gender dynamics.
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Affiliation(s)
- Li Li
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health , University of California, Los Angeles , Los Angeles , California , USA
| | - Chunqing Lin
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health , University of California, Los Angeles , Los Angeles , California , USA
| | - Guoping Ji
- b Anhui Provincial Center for Women and Child Health , Hefei , China
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Biello KB, Oldenburg CE, Safren SA, Rosenberger JG, Novak DS, Mayer KH, Mimiaga MJ. Multiple syndemic psychosocial factors are associated with reduced engagement in HIV care among a multinational, online sample of HIV-infected MSM in Latin America. AIDS Care 2016; 28 Suppl 1:84-91. [PMID: 26883009 PMCID: PMC4828614 DOI: 10.1080/09540121.2016.1146205] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Latin America has some of the highest levels of antiretroviral therapy (ART) coverage of any developing region in the world. Early initiation and optimal adherence to ART are necessary for improved health outcomes and reduction in onward transmission. Previous work has demonstrated the role of psychosocial problems as barriers to uptake and adherence to ART, and recently, a syndemic framework has been applied to the role of multiple psychosocial syndemic factors and adherence to ART, in the USA. However, to our knowledge, these associations have not been investigated outside of the USA, nor in a multi-country context. To address these gaps, we assessed the association between multiple co-occurring psychosocial factors and engagement in HIV-related medical care and adherence to ART among a large, multinational sample of sexually-active HIV-infected men who have sex with men in Latin America. Among the 2020 respondents, 80.7% reported currently receiving HIV-related medical care, 72.3% reported currently receiving ART; among those, 62.5% reported 100% adherence. Compared with experiencing no psychosocial health problems, experiencing five or more psychosocial health problems is associated with 42% lower odds of currently receiving HIV-related medical care (adjusted odds ratio, aOR = 0.58, 95% CI 0.36, 0.95) and of currently receiving ART (aOR = 0.58, 95% CI 0.38, 0.91). The number of psychosocial health problems experienced was associated with self-reported ART adherence in a dose–response relationship; compared to those with none of the factors, individuals with one syndemic factor had 23% lower odds (aOR = 0.77, 95% CI 0.60, 0.97) and individuals with five or more syndemic factors had 72% lower odds (aOR = 0.28, 95% CI 0.14, 0.55) of reporting being 100% adherent to ART. Addressing co-occurring psychosocial problems as potential barriers to uptake and adherence of ART in Latin America may improve the effectiveness of secondary prevention interventions.
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Affiliation(s)
- Katie B Biello
- a Department of Behavioral and Social Sciences , Brown University School of Public Health , Providence , RI , USA.,b The Fenway Institute, Fenway Health , Boston , MA , USA
| | | | - Steven A Safren
- d Department of Psychology , University of Miami , Miami , FL , USA
| | - Joshua G Rosenberger
- e Department of Biobehavioral Health, Penn State University, University Park , PA , USA
| | - David S Novak
- f OLB Research Institute, Online Buddies, Inc ., Cambridge , MA , USA
| | - Kenneth H Mayer
- b The Fenway Institute, Fenway Health , Boston , MA , USA.,g Department of Infectious Disease , Harvard Medical School/Beth Israel Deaconess Medical Center , Boston , MA , USA
| | - Matthew J Mimiaga
- a Department of Behavioral and Social Sciences , Brown University School of Public Health , Providence , RI , USA.,b The Fenway Institute, Fenway Health , Boston , MA , USA
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Sweeney SM, Vanable PA. The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature. AIDS Behav 2016; 20:29-50. [PMID: 26303196 DOI: 10.1007/s10461-015-1164-1] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This paper provides a review of the quantitative literature on HIV-related stigma and medication adherence, including: (1) synthesis of the empirical evidence linking stigma to adherence, (2) examination of proposed causal mechanisms of the stigma and adherence relationship, and (3) methodological critique and guidance for future research. We reviewed 38 studies reporting either cross-sectional or prospective analyses of the association of HIV-related stigma to medication adherence since the introduction of antiretroviral therapies (ART). Although there is substantial empirical evidence linking stigma to adherence difficulties, few studies provided data on psychosocial mechanisms that may account for this relationship. Proposed mechanisms include: (a) enhanced vulnerability to mental health difficulties, (b) reduction in self-efficacy, and (c) concerns about inadvertent disclosure of HIV status. Future research should strive to assess the multiple domains of stigma, use standardized measures of adherence, and include prospective analyses to test mediating variables.
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Affiliation(s)
- Shannon M Sweeney
- Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244-2340, USA.
| | - Peter A Vanable
- Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244-2340, USA.
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Chambers LA, Rueda S, Baker DN, Wilson MG, Deutsch R, Raeifar E, Rourke SB. Stigma, HIV and health: a qualitative synthesis. BMC Public Health 2015; 15:848. [PMID: 26334626 PMCID: PMC4557823 DOI: 10.1186/s12889-015-2197-0] [Citation(s) in RCA: 201] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Accepted: 08/27/2015] [Indexed: 11/10/2022] Open
Abstract
Background HIV-related stigma continues to negatively impact the health and well-being of people living with HIV, with deleterious effects on their care, treatment and quality of life. A growing body of qualitative research has documented the relationship between HIV-related stigma and health. This review aims to synthesize qualitative evidence that explored the intersections of stigma and health for people with HIV. Methods A thematic summary was conducted that was guided by the qualitative metasummary technique developed by Sandelowski and Barraso. Literature searches yielded 8,622 references of which 55 qualitative studies were identified that illustrated HIV-related stigma in the context of health. Results The metasummary classified qualitative findings into three overarching categories: conceptualizing stigma which identified key dimensions of HIV-related stigma; experiencing stigma which highlighted experiences of stigma in the health context, and managing stigma which described ways in which stigma is avoided or addressed. To better illustrate these connections, the qualitative literature was summarized into the following themes: stigma within health care settings, the role of stigma in caring for one’s health, and strategies to address HIV-related stigma in the health context. A number of health care practices were identified – some rooted in institutional practices, others shaped by personal perceptions held by practitioners – that could be stigmatizing or discriminatory towards people with HIV. There existed interconnections between enacted stigma and felt stigma that influenced health care utilization, treatment adherence, and overall health and well-being of people with HIV. Intersectional stigma also emerged as instrumental in the stigma experiences of people living with HIV. A number of strategies to address stigma were identified including social support, education, self-efficacy, resilience activities, and advocacy. Conclusion This review of the qualitative evidence indicates that HIV-related stigma within health contexts is a broad social phenomenon that manifests within multiple social spheres, including health care environments. Findings from this review indicate that future stigma research should consider the social structures and societal practices – within and outside of health care environments – that perpetuate and reinforce stigma and discrimination towards people with HIV. Electronic supplementary material The online version of this article (doi:10.1186/s12889-015-2197-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lori A Chambers
- School of Social Work, McMaster University, Kenneth Taylor Hall, KTH-319, 1280 Main St. West, Hamilton, ON, L8S 4M4, Canada.
| | - Sergio Rueda
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, c/o Research Services Office, 33 Russell St., T100, Toronto, ON, M5S 2S1, Canada. .,Department of Psychiatry, University of Toronto, 250 College St., 8th floor, Toronto, ON, M5T 1R8, Canada. .,Institute for Work & Health, 481 University Ave., Suite 800, Toronto, ON, M5G 2E9, Canada.
| | - D Nico Baker
- Ontario HIV Treatment Network, 1300 Yonge St., Suite 600, Toronto, ON, M4T 1X3, Canada.
| | - Michael G Wilson
- Ontario HIV Treatment Network, 1300 Yonge St., Suite 600, Toronto, ON, M4T 1X3, Canada. .,Department of Clinical Epidemiology and Biostatistics, McMaster University, Communications Research Laboratory, CRL-209, 1280 Main St. West, Hamilton, ON, L8S 4M4, Canada. .,Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main St. West, Hamilton, ON, L8S 4M4, Canada. .,McMaster Health Forum, McMaster University, Mills Memorial Library, MML-417, 1280 Main St. West, Hamilton, ON, L8S 4M4, Canada.
| | - Rachel Deutsch
- Ontario HIV Treatment Network, 1300 Yonge St., Suite 600, Toronto, ON, M4T 1X3, Canada.
| | - Elmira Raeifar
- Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Rd., White Plains, NY, 10605, USA.
| | - Sean B Rourke
- Department of Psychiatry, University of Toronto, 250 College St., 8th floor, Toronto, ON, M5T 1R8, Canada. .,Ontario HIV Treatment Network, 1300 Yonge St., Suite 600, Toronto, ON, M4T 1X3, Canada. .,Centre for Research on Inner City Health, The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria St, Toronto, ON, M5B 1 T8, Canada.
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- Ontario HIV Treatment Network, 1300 Yonge St., Suite 600, Toronto, ON, M4T 1X3, Canada
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Valle A, Treviño AC, Zambrano FF, Urriola KE, Sánchez LA, Elizondo JE. Perceived HIV-Associated Stigma among HIV-Seropositive Men: Psychometric Study of HIV Stigma Scale. Front Public Health 2015; 3:171. [PMID: 26191524 PMCID: PMC4490212 DOI: 10.3389/fpubh.2015.00171] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 06/19/2015] [Indexed: 12/03/2022] Open
Abstract
Objectives To assess the internal consistency and factor structure of the abridged Spanish version of the Berger HIV Stigma Scale (HSS-21), to provide evidence for its convergent and discriminant validity, and to describe perceived stigma in an urban population from northeast Mexico. Methods Seventy-five HIV-positive men who have sex with men (MSM) were recruited. Participants answered the Spanish versions of three Likert-type scales: HSS-21, Robsenberg’s self-esteem scale, and the abbreviated version of the Zung’s Depression Scale. Results HSS-21 showed high reliability and validity; its factor structure included four components: concern with public attitudes; negative self-image; disclosure concerns; and enacted stigma. The level of stigma was high in 27 out of 75 (36%) participants; nevertheless, the score found in the component related to disclosure concerns indicated high level of stigma in 68% of participants. The score of HSS-21 was positively correlated with the score of depression and negatively correlated with the score of self-esteem. Conclusion Results demonstrated high reliability for the HSS-21; correlations with other scales supported its validity. This scale demonstrated to be a practical tool for assessing stigma among Mexican HIV-positive MSM. High level of stigma was found only in the factor related to disclosure concerns. Policy implications Identifying HIV-associated stigma through a short, reliable, and validated instrument will allow the development of interventions that cope and manage stigma in HIV-positive MSM. HSS-21 distinguishes between different dimensions of stigma and will contribute to a better understanding of this phenomenon.
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Affiliation(s)
- Adrian Valle
- Medical and Health Sciences Program, Department of Basic Sciences, Instituto Tecnológico de Monterrey , Monterrey , Mexico
| | - Ana Cecilia Treviño
- Medical and Surgical Dentist Program, Instituto Tecnológico de Monterrey , Monterrey , Mexico
| | | | | | - Luis Antonio Sánchez
- Clinical Microbiology and Infectious Diseases, Universidad de Monterrey , San Pedro Garza García , Mexico ; Secretaria de Salud de Nuevo León, Nuevo Leon State Council for AIDS Prevention (COESIDA NL) , Monterrey , Mexico
| | - Jesus Eduardo Elizondo
- Medical and Health Sciences Program, Department of Basic Sciences, Instituto Tecnológico de Monterrey , Monterrey , Mexico ; Doctoral Program in Biotechnology, Biopharmaceuticals and Biopharmaceutical Engineering, Instituto Tecnológico de Monterrey , Monterrey , Mexico ; Doctoral Program in Dentistry, Research in Dentistry, Universitat Internacional de Catalunya , Barcelona , Spain
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Kumar S, Mohanraj R, Rao D, Murray KR, Manhart LE. Positive coping strategies and HIV-related stigma in south India. AIDS Patient Care STDS 2015; 29:157-63. [PMID: 25612135 DOI: 10.1089/apc.2014.0182] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Whether perceived or enacted, HIV-related stigma is widespread in India, and has had a crippling effect on People Living with HIV/AIDS (PLHA). Research has shown that a positive attitude towards the illness sets a proactive framework for the individual to cope with his or her infection; therefore, healthy coping mechanisms are essential to combat HIV-related stigma. This qualitative study involving in-depth interviews and focus group discussions with PLHA affiliated with HIV support groups in South India explored positive coping strategies employed by PLHA to deal with HIV-related stigma. Interviews and focus group discussions were translated, transcribed, and analyzed for consistent themes. Taboos surrounding modes of transmission, perceiving sex workers as responsible for the spread of HIV, and avoiding associating with PLHA provided the context of HIV-related stigma. Despite these challenges, PLHA used several positive strategies, classified as Clear Knowledge and Understanding of HIV, Social Support and Family Well-Being, Selective Disclosure, Employment Building Confidence, and Participation in Positive Networks. Poor understanding of HIV and fears of being labeled immoral undermined healthy coping behavior, while improved understanding, affiliation with support groups, family support, presence of children, and financial independence enhanced PLHA confidence. Such positive coping behaviours could inform culturally relevant interventions.
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Affiliation(s)
- Shuba Kumar
- Samarth, Mylapore, Chennai, Tamil Nadu, India
| | | | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, Washington, United States
| | - Katherine R. Murray
- Department of Global Health, University of Washington, Seattle, Washington, United States
| | - Lisa E. Manhart
- Department of Global Health, University of Washington, Seattle, Washington, United States
- Department of Epidemiology, University of Washington, Seattle, Washington, United States
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Kohler PK, Ondenge K, Mills LA, Okanda J, Kinuthia J, Olilo G, Odhiambo F, Laserson KF, Zierler B, Voss J, John-Stewart G. Shame, guilt, and stress: Community perceptions of barriers to engaging in prevention of mother to child transmission (PMTCT) programs in western Kenya. AIDS Patient Care STDS 2014; 28:643-51. [PMID: 25361205 DOI: 10.1089/apc.2014.0171] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
While global scale-up of prevention of mother-to-child transmission of HIV (PMTCT) services has been expansive, only half of HIV-infected pregnant women receive antiretroviral regimens for PMTCT in sub-Saharan Africa. To evaluate social factors influencing uptake of PMTCT in rural Kenya, we conducted a community-based, cross-sectional survey of mothers residing in the KEMRI/CDC Health and Demographic Surveillance System (HDSS) area. Factors included referrals and acceptability, HIV-related stigma, observed discrimination, and knowledge of violence. Chi-squared tests and multivariate regression analyses were used to detect stigma domains associated with uptake of PMTCT services. Most HIV-positive women (89%) reported blame or judgment of people with HIV, and 46% reported they would feel shame if they were associated with someone with HIV. In multivariate analyses, shame was significantly associated with decreased likelihood of maternal HIV testing (Prevalence Ratio 0.91, 95% Confidence Interval 0.84-0.99), a complete course of maternal antiretrovirals (ARVs) (PR 0.73, 95% CI 0.55-0.97), and infant HIV testing (PR 0.86, 95% CI 0.75-0.99). Community perceptions of why women may be unwilling to take ARVs included stigma, guilt, lack of knowledge, denial, stress, and despair or futility. Interventions that seek to decrease maternal depression and internalization of stigma may facilitate uptake of PMTCT.
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Affiliation(s)
- Pamela K. Kohler
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Psychosocial and Community Health, University of Washington, Seattle, Washington
| | - Kenneth Ondenge
- Kenya Medical Research Institute (KEMRI)/Centers for Disease Control and Prevention (CDC) Research and Public Health Collaboration, Kisumu, Kenya
| | - Lisa A. Mills
- Kenya Medical Research Institute (KEMRI)/Centers for Disease Control and Prevention (CDC) Research and Public Health Collaboration, Kisumu, Kenya
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - John Okanda
- Kenya Medical Research Institute (KEMRI)/Centers for Disease Control and Prevention (CDC) Research and Public Health Collaboration, Kisumu, Kenya
| | - John Kinuthia
- Kenyatta National Hospital/ University of Nairobi, Nairobi, Kenya
| | - George Olilo
- Kenya Medical Research Institute (KEMRI)/Centers for Disease Control and Prevention (CDC) Research and Public Health Collaboration, Kisumu, Kenya
| | - Frank Odhiambo
- Kenya Medical Research Institute (KEMRI)/Centers for Disease Control and Prevention (CDC) Research and Public Health Collaboration, Kisumu, Kenya
| | - Kayla F. Laserson
- Kenya Medical Research Institute (KEMRI)/Centers for Disease Control and Prevention (CDC) Research and Public Health Collaboration, Kisumu, Kenya
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brenda Zierler
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| | - Joachim Voss
- Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington
- Department of Medicine, University of Washington, Seattle, Washington
- Department of Pediatrics, University of Washington, Seattle, Washington
- Department of Epidemiology, University of Washington, Seattle, Washington
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Franke MF, Nelson AK, Muñoz M, Cruz JS, Atwood S, Lecca L, Shin SS. Validation of 2 Spanish-Language Scales to Assess HIV-Related Stigma in Communities. J Int Assoc Provid AIDS Care 2014; 14:527-35. [PMID: 25294853 DOI: 10.1177/2325957414547738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report the psychometric properties of 2 Spanish-language scales designed to measure (1) opinions about HIV in the community and particularly among health care workers and (2) observed acts of stigma toward people living with HIV/AIDS (PLWHA) by health care workers. The Opinions about HIV Scale included 3 components (policy, avoidance, and empathy) and 9 items, while an adapted version of the HIV/AIDS Stigma Instrument-Nurse, designed to capture acts of stigma, included 2 components (discrimination related to clinical care and refusal to share or exchange food/gifts). Scales demonstrated good reliability and construct validity. Relative to community health workers, treatment supporters were more likely to have stigmatizing opinions related to avoidance and empathy. We offer 2 Spanish-language scales that could be used to identify populations with high levels of stigmatizing opinions and behaviors toward PLWHA. Formal training of health care workers, especially treatment supporters, may raise awareness and reduce stigma toward HIV.
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Affiliation(s)
- Molly F Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Partners In Health / Socios En Salud, Lima, Peru
| | - Adrianne K Nelson
- Partners In Health / Socios En Salud, Lima, Peru Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Sidney Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - Leonid Lecca
- Partners In Health / Socios En Salud, Lima, Peru
| | - Sonya S Shin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA Partners In Health / Socios En Salud, Lima, Peru Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
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Kleinman NJ, Manhart LE, Mohanraj R, Kumar S, Jeyaseelan L, Rao D, Simoni JM. Antiretroviral therapy adherence measurement in non-clinical settings in South India. AIDS Care 2014; 27:248-54. [PMID: 25119585 DOI: 10.1080/09540121.2014.946382] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Optimal adherence to antiretroviral therapy (ART) is key to viral suppression, but may be impeded by psychosocial consequences of HIV-infection such as stigma and depression. Measures of adherence in India have been examined in clinic populations, but little is known about the performance of these measures outside clinical settings. We conducted a cross-sectional study of 151 Tamil-speaking people living with HIV/AIDS (PLHA) in India recruited through HIV support networks and compared single item measures from the Adult AIDS Clinical Trial Group (AACTG) scale, a visual analog scale (VAS), and a question on timing of last missed dose. Depression was measured using the Major Depression Inventory (MDI) and HIV-related stigma was measured using an adaptation of the Berger Stigma Scale. Mean age was 35.6 years (SD ± 5.9); 55.6% were male; mean MDI score was 11.9 (SD ± 9.1); and mean stigma score was 67.3 (SD ± 12.0). Self-reported perfect adherence (no missed doses) was 93.3% using the AACTG item, 87.1% using last missed dose, and 83.8% using the VAS. The measures had moderate agreement with each other (kappa 0.45-0.57). Depression was associated with lower adherence irrespective of adherence measure used, and remained significantly associated in multivariable analyses adjusting for age and marital status. Stigma was not associated with adherence irrespective of the measure used. The VAS captured the greatest number of potentially non-adherent individuals and may be useful for identifying PLHA in need of adherence support. Given the consistent and strong association between poorer adherence and depression, programs that jointly address adherence and mental health for PLHA in India may be more effective than programs targeting only one.
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Affiliation(s)
- Nora J Kleinman
- a Department of Epidemiology , University of Washington , Seattle , WA , USA
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Patel R, Baum S, Grossman D, Steinfeld R, Onono M, Cohen C, Bukusi E, Newmann S. HIV-positive men's experiences with integrated family planning and HIV services in western Kenya: integration fosters male involvement. AIDS Patient Care STDS 2014; 28:418-24. [PMID: 24927494 PMCID: PMC4932786 DOI: 10.1089/apc.2014.0046] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A growing body of evidence indicates that integrating family planning (FP) services into HIV care is effective at improving contraceptive uptake among HIV-positive women in resource-poor settings, yet little research has examined HIV-positive men's experiences with such integration. We conducted in-depth interviews with 21 HIV-positive men seeking care at HIV clinics in Nyanza, Kenya. All clinics were intervention sites for a FP/HIV service integration cluster-randomized trial. Grounded theory was used to code and analyze the data. Our findings highlight men's motivations for FP, reasons why men prefer obtaining their FP services, which include education, counseling, and commodities, at HIV care clinics, and specific ways in which integrated FP/HIV services fostered male inclusion in FP decision-making. In conclusion, men appear invested in FP and their inclusion in FP decision-making may bolster both female and male agency. Men's positive attitudes towards FP being provided at HIV care clinics supports the programmatic push towards integrated delivery models for FP and HIV services.
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Affiliation(s)
- Rena Patel
- Division of Infectious Diseases, University of California San Francisco, San Francisco, California
| | - Sarah Baum
- Ibis Reproductive Health, Oakland, California
| | - Daniel Grossman
- Ibis Reproductive Health, Oakland, California
- Bixby Center for Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Rachel Steinfeld
- Bixby Center for Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Nyanza, Kenya
| | - Craig Cohen
- Bixby Center for Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
| | - Elizabeth Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute, Kisumu, Nyanza, Kenya
| | - Sara Newmann
- Bixby Center for Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California
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Earnshaw VA, Smith LR, Shuper PA, Fisher WA, Cornman DH, Fisher JD. HIV stigma and unprotected sex among PLWH in KwaZulu-Natal, South Africa: a longitudinal exploration of mediating mechanisms. AIDS Care 2014; 26:1506-13. [PMID: 25040218 DOI: 10.1080/09540121.2014.938015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Social and structural factors including HIV stigma are theorized to drive global disparities in HIV prevalence. This study tests whether HIV self-stigma, or experiences of stigma at the individual level, is associated with engagement in unprotected sex among people living with HIV (PLWH) in KwaZulu-Natal, South Africa, where 37.4% of adults are living with HIV compared with 0.8% worldwide. It further explores whether depressive symptoms, HIV status disclosure to sex partners, and/or condom use attitudes mediate potential associations between HIV self-stigma and unprotected sex. Participants, including 924 PLWH, were recruited from primary care clinics and completed baseline, 6-, 12-, and 18-month survey assessments between 2008 and 2011. Hierarchical linear modeling analyses were used to examine longitudinal within-subjects associations between HIV self-stigma, mediators, and unprotected sex with both HIV-negative/unknown and HIV-positive partners. Results demonstrate that HIV self-stigma was prospectively associated with greater likelihood of unprotected sex with HIV-negative/unknown partners. None of the variables explored significantly mediated this association. HIV self-stigma was also prospectively associated with greater likelihood of unprotected sex with HIV-positive partners via the mediators of greater depressive symptoms and more negative condom use attitudes. The current study suggests that HIV self-stigma undermines HIV secondary prevention and care efforts among PLWH in KwaZulu-Natal. It is therefore critical to address HIV stigma at the social/structural level to reduce HIV self-stigma at the individual level and ultimately curb global disparities in HIV prevalence. In the absence of widespread social/structural change, interventions that treat depressive symptoms and encourage more positive condom use attitudes despite the existence of HIV stigma may buffer associations between HIV self-stigma and unprotected sex with HIV-positive partners among PLWH in KwaZulu-Natal.
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Affiliation(s)
- Valerie A Earnshaw
- a Center for Interdisciplinary Research on AIDS , Yale University , New Haven , CT , USA
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Oldenburg CE, Biello KB, Colby D, Closson EF, Mai T, Nguyen T, Nguyen NA, Mimiaga MJ. Stigma related to sex work among men who engage in transactional sex with men in Ho Chi Minh City, Vietnam. Int J Public Health 2014; 59:833-40. [PMID: 24858522 DOI: 10.1007/s00038-014-0562-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 03/24/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVES Male sex workers (MSW) in Vietnam face high levels of stigma related to sex work, which may be associated with depression and increased vulnerability to HIV. METHODS In 2010, 300 MSW completed a behavioral and psychosocial survey. Multivariable models assessed factors associated with sex work-related stigma and the association between stigma and depression. RESULTS Factors associated with increased stigma included having disclosed sexual orientation to healthcare workers (b 1.75, 95 % CI 0.69-2.80), meeting clients in the street/park (b 1.42, 95 % CI 0.32-2.52), and having been forced to have sex without a condom (b 2.36, 95 % CI 1.27-3.45). Factors associated with decreased stigma included meeting clients via the telephone or internet (b -1.26, 95 % CI -2.39 to -0.12) and receiving financial support from family or friends (b -1.31, 95 % CI -2.46 to -0.17). Stigma was significantly associated with increased odds of depression (AOR 1.07, 95 % CI 1.01-1.15). CONCLUSIONS Addressing stigma and depression in HIV prevention interventions is crucial for tailoring these programs to MSWs' needs, and may result in decreased HIV spread.
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Shacham E, Rosenburg N, Önen NF, Donovan MF, Overton ET. Persistent HIV-related stigma among an outpatient US clinic population. Int J STD AIDS 2014; 26:243-50. [PMID: 24828557 DOI: 10.1177/0956462414533318] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite advancements in the public's understanding of HIV infection, felt stigma towards individuals living with HIV persists. Stigma has been associated with adverse health outcomes, including poor adherence to care, and increased participation in HIV transmission risk behaviours. We evaluated the level of felt stigma and its relationship to other psychosocial and medical factors among a sample of 201 individuals with HIV engaged in care. The overall mean stigma score, as measured by the Reece Stigma Scale, was 21.7 (SD 8.7). In univariate analysis, felt stigma scores were higher among women, African Americans, younger participants, and individuals with less education. Higher felt stigma scores were also found among individuals who reported having fair to poor overall health, moderate to severe symptoms of depression and anxiety, and those with a current diagnosis of alcohol dependence, generalised anxiety disorder, agoraphobia, pain disorder, and current smokers. Higher felt stigma scores were independently associated with individuals with anxiety symptoms. These analyses highlight that stigma persists among individuals with HIV and may play an important role in HIV care. The relationship between psychiatric disorders and psychosocial factors highlights an opportunity to develop interventions that will address these common comorbidities and reduce stigma.
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Affiliation(s)
- Enbal Shacham
- College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
| | - Neal Rosenburg
- School of Nursing, Nevada State College, Henderson, NV, USA
| | - Nur F Önen
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | | | - E Turner Overton
- Division of Infectious Diseases, Department of Medicine, University of Alabama, Birmingham, AL, USA
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Kingori C, Haile ZT, Ngatia P. Depression symptoms, social support and overall health among HIV-positive individuals in Kenya. Int J STD AIDS 2014; 26:165-72. [PMID: 24759561 DOI: 10.1177/0956462414531933] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In Kenya, there was a reported decline in HIV incidence and prevalence among those aged 15 to 64 years and children. Despite the decline, closer assessment of psychosocial issues like depression, contextual factors (family and community), and social support is necessary given the likely impact on overall health and HIV prevention. This paper examines an association between symptoms of depression and social support on overall health among HIV-positive participants recruited from an HIV clinic in Kenya. Descriptive statistics and logistic regression analyses were utilized. Findings reveal that compared to those with minimal depression (referent category) participants with mild, moderate, moderately severe/severe depression had higher odds of having poor health. For social support, compared with participants with no social support (referent category), participants with high social support had lower odds of having poor overall health in both unadjusted and multivariable-adjusted models. In conclusion, this study suggests that HIV clinics and interventions need to focus more on the psychological and/or mental health status of HIV-infected individuals while providing avenues such as social support groups that can be a buffer against the negative impact of HIV infection and depression on overall health outcomes.
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Affiliation(s)
- Caroline Kingori
- Department of Social and Public Health, Ohio University, Athens, OH, USA
| | - Zelalem T Haile
- Department of Epidemiology, West Virginia University School of Public Health, Morgantown, WV, USA
| | - Peter Ngatia
- African Medical Research Foundation, Nairobi, Kenya
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Lyimo RA, Stutterheim SE, Hospers HJ, de Glee T, van der Ven A, de Bruin M. Stigma, disclosure, coping, and medication adherence among people living with HIV/AIDS in Northern Tanzania. AIDS Patient Care STDS 2014; 28:98-105. [PMID: 24517541 DOI: 10.1089/apc.2013.0306] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study examines a proposed theoretical model examining the interrelationships between stigma, disclosure, coping, and medication adherence among 158 HIV-infected patients on antiretroviral therapy (ART) in northern Tanzania. Perceived and self-stigma, voluntary and involuntary disclosure, positive and negative coping, and demographics were assessed by trained interviewers, and self-reported adherence was collected during 5 months follow-up. Data were examined using correlation and regression analyses. The analyses showed that perceived stigma is primarily related to involuntary disclosure, whereas self-stigma is related to voluntary disclosure. Religious coping positively relates to acceptance, whereas perceived stigma explains higher levels of denial of HIV status. Lastly, adherence was negatively affected by alcohol use, self-stigma, and denial. We conclude that adherence is predominantly predicted by negative rather than positive coping mechanisms. Therefore, substituting maladaptive coping mechanisms like denial and alcohol use with a more adaptive coping style may be an important strategy to improve long-term ART adherence and well-being of patients. Moreover, this study showed that it is useful to examine both involuntary and voluntary disclosure when studying its relation with stigma.
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Affiliation(s)
- Ramsey A Lyimo
- 1 Kilimanjaro Clinical Research Institute/Kilimanjaro Christian Medical Center ; Moshi, Tanzania
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Kingori C, Reece M, Obeng S, Murray M, Shacham E, Dodge B, Akach E, Ngatia P, Ojakaa D. Psychometric evaluation of a cross-culturally adapted felt stigma questionnaire among people living with HIV in Kenya. AIDS Patient Care STDS 2013; 27:481-8. [PMID: 23968206 DOI: 10.1089/apc.2012.0403] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Psychometric properties of an 18-item HIV felt stigma questionnaire were evaluated utilizing data collected from a diverse ethnic and socioeconomic group of 370 people living with HIV/AIDS and receiving HIV/AIDS-related health services at an HIV clinic in Kenya. Factor analyses revealed a four factor solution (public attitudes, ostracize, discrimination, personal life disrupted) based on the Scree plot with explained variance of 44% that had Eigen values greater than 1.00. The retained felt stigma items revealed a Cronbach's alpha coefficient of 0.828, while the four factors had coefficient alphas ranging from 0.675 to 0.799. The adapted retained questionnaire was deemed a practical guide for measuring felt stigma in a Kenyan cultural context to necessitate provision of the most effective HIV-related mental health services to individuals living with HIV in Kenya.
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Affiliation(s)
- Caroline Kingori
- Department of Social and Public Health, Ohio University, Athens, Ohio
| | - Michael Reece
- Center for Sexual Health Promotion, School of Health and Physical Education, Indiana University, Bloomington, Indiana
| | - Samuel Obeng
- African Studies Program, School of Health and Physical Education, Indiana University, Bloomington, Indiana
| | - Maresa Murray
- Department of Applied Health Science, School of Health and Physical Education, Indiana University, Bloomington, Indiana
| | - Enbal Shacham
- Department of Behavioral Sciences and Health Education, School of Public Health, Saint Louis University, St. Louis, Missouri
| | - Brian Dodge
- Center for Sexual Health Promotion, School of Health and Physical Education, Indiana University, Bloomington, Indiana
| | - Emannuel Akach
- African Medical Research Foundation (AMREF), Nairobi, Kenya
| | - Peter Ngatia
- African Medical Research Foundation (AMREF), Nairobi, Kenya
| | - David Ojakaa
- African Medical Research Foundation (AMREF), Nairobi, Kenya
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