Strategies for gender-equitable HIV services in rural India

A systematic review of sex and gender differences in treatment outcome of inflammatory skin diseases: Is it time for new guidelines?

Gender- and sex-specific differences in medicine were long-time disregarded. Despite numerous indications of gender- and sex-specific influences on the treatment of dermatological conditions, these have not yet been systematically investigated. To meet this unmet need, we conducted the present systematic review on the topic of gender and sex differences in the treatement outcome of skin diseases. Embase (via Ovid), PubMed Medline and Web of Science were searched, in between January 2001 and December 2022. English and german randomized controlled trials, prospective and retrospective cohorts and case-control studies that examined differences between men and women in treatment outcomes of skin diseases were included. Two authors independently screened the reports for eligibility, one extracted all data (the second double-checked) and critically appraised the quality and risk of bias of the studies. Eighty-three reports were included. The largest share of the identified publications focused on gender differences in psoriasis and psoriatic arthritis (n = 49), followed by melanoma (n = 8) and sporadic studies (n < 5) of inflammatory, infectious and autoimmune skin diseases. The main topics in which gender differences could be identified were choice of treatment, time to initiation of treatment, therapy response, adverse events, adherence and treatment satisfaction. For psoriasis, gender differences could be found in all aspects, while for the other skin diseases specific publications on gender differences are still missing. This systematic review shows numerous gender differences but also reveals major gaps in gender-specific care in dermatology which should be narrowed in the upcoming years to optimize a patient-centred, individualized, gender-equal healthcare. PROSPERO Registration: CRD42022306626.

Have Policies Tackled Gender Inequalities in Health? A Scoping Review

Gender is recognized as one of the most relevant determinants of health inequalities. This scoping review sought to identify and analyse policies, either implemented or formulated as proposals, which aimed to reduce gender inequalities in health. We searched Medline, Web of Science, and Scielo. Of 2895 records, 91 full text articles were analysed, and 33 papers were included. Of these papers, 22 described the process of formulation, implementation, or evaluation of policies whose aim was to reduce gender inequalities in health; six focused on recommendations, and the remaining five dealt with both issues. Our review showed that the policies aimed at reducing gender inequalities in health, either implemented or formulated as proposals, are scarce. Moreover, despite some success, overall progress has been slow. The studies show failures in design and particularly in the implementation process. We found a lack of awareness and capacity in the policy-making progress, under-financing, bureaucratization, shortage of relevant data, and absence of women’s participation in decision-making. Therefore, an emphasis on the design and implementation of gender-sensitive policies seems essential to advance gender equality in health. This scoping review gathers evidence to support the design of such policies and recommendations that can facilitate their implementation.

Anti-retroviral therapy failure in HIV-1 infected pregnant women and its associated risk of HIV transmission

BACKGROUND

The HIV perinatal transmission in India even after interventions is still high. The anti-retroviral therapy failure rate and the risk of HIV vertical transmission to infants from women with failed treatment during pregnancy also largely remains unevaluated.

METHODS

This is a prospective, observational and follow-up study of 18 months to determine the association of ART failure in pregnant women and the subsequent risk of HIV transmission to their infants. A total of 81 mothers were evaluated for ART success/failure by analysing their viral loads.

RESULTS

Analyses revealed that a high percentage (19.75%) of women on ART had high viral loads, while the overall HIV transmission rate to the infants was 8.64%. The rate of transmission from women with high viral load was significantly high compared to women with low viral load (37.5% vs. 1.54%; p = 0.0015). CD₄ level was not associated with HIV transmission. However, CD₄ levels in women, who had successful or failed ART, were significantly different (p = 0.0031). Factors such as mother's age, baby's sex and weight as well as delivery mode were not associated with HIV transmission, however, breastfeeding and viral loads were found to be independently associated with HIV transmission to the neonates.

CONCLUSIONS

This study highlights that a significant proportion of women on ART had impaired viral load control. The rate of HIV transmission to infants was also significantly high among these women. This warrants viral load monitoring of HIV infected women to reduce the overall transmission to the infants.

"They Kept Away": Social Isolation of Cisgender Women Living with HIV in Hyderabad, India

Social isolation of cisgender women living with HIV has been recognized as a barrier to early detection of the virus, disclosure of HIV status to partners, and access to healthcare and social work services. The goal of this study is to explore how social isolation and depression affect cisgender women living with HIV in Hyderabad, India. Sixteen cisgender women living with HIV were asked to complete in-depth interviews regarding their experiences with HIV stigma and depression. All interviews were digitally audio-recorded in Hindi or Telugu, then translated, transcribed, and analyzed using thematic content analysis by two to three coders. Three main themes emerged from the qualitative interviews among these cisgender women living with HIV: (1) "They kept away": Experiences with social isolation; (2) "I thought people would think badly about me": Perceived experiences of discrimination; and (3) "I will live till I die": Suicidality, resilience, and gaining hope. Our findings reinforce the need for emphasis on culturally appropriate interventions for depression for cisgender women living with HIV in India, including greater access to mental health resources, greater availability of trained counselors that share the same gender and are native speakers of Hindi or Telugu, and increased family and community support for socially isolated individuals.

Incidence, prevalence and associated factors of mother-to-child transmission of HIV, among children exposed to maternal HIV, in Belgaum district, Karnataka, India

BACKGROUND

India lacks data on the incidence of Paediatric HIV. In 2010, the Indian Council of Medical Research commissioned a task force study to estimate the paediatric HIV burden in Belgaum district, Karnataka, India. We estimated the HIV incidence, prevalence and associated risk factors of mother to child transmission of HIV among children exposed to maternal HIV by age 24 months.

METHODS

We included Belgaum resident pregnant women who tested HIV positive between January 1st, 2011 and May 31st, 2013 and who provided consent. Their babies were tested for HIV at three time intervals using DNA PCR dry blood spot (DBS) method at 6-10 weeks and 6-9 months, and using Antibody tests at 18-24 months of age. We estimated cumulative incidence using survival analysis that considered censoring of cases and prevalence rates of HIV by age 24 months. Using competing-risk survival regression model, we examined the correlates of transmission of HIV among babies exposed to maternal HIV.

RESULTS

Among 487 children of HIV positive mothers recruited in the study, the cumulative incidence rate by 24 months of age was 4.8 per 1000 person months [95% CI: 3.5-6.6]. The HIV prevalence rate among babies exposed to maternal HIV until 24 months was 7.8% [95% CI: 5.7-10.7]. Mother's age above 30 years, and breastfeeding duration of more than six months were factors that significantly increased the HIV transmission; adjusted hazard ratio (AHR) 6.98 [95% CI: 1.73-28.16] and 5.28 [95% CI, 1.75-15.90], respectively. The risk of MTCT was significantly reduced if both mother and baby had received Nevirapine at delivery [AHR 0.25; 95%CI: 0.10-0.61] and if either mother or baby had been given Nevirapine at delivery [AHR 0.12; 95%CI: 0.03-0.49].

CONCLUSION

The study findings suggest that mother's age above 30 years and breastfeeding beyond 26 weeks is associated with higher rates of HIV transmission from mother to child. It confirms the benefits of providing anti-retrovirals (Nevirapine) in reducing mother to child transmission of HIV. Effective strategies to promote safe infant feeding practices, including avoidance of mixed feeding beyond 26 weeks among HIV infected mothers, is critical to reduce incidence of paediatric HIV in India.

The Role of HIV Stigma in ART Adherence and Quality of Life Among Rural Women Living with HIV in India

HIV stigma continues to be a barrier to physical and mental health among people living with HIV globally, especially in vulnerable populations. We examined how stigma is associated with health outcomes and quality of life among rural women living with HIV in South India (N = 600). Interviewer-administered measures assessed multiple dimensions of stigma, as well as loneliness, social support, ART adherence, time since diagnosis, and quality of life. Internalized stigma and a lack of social support were associated with a lower quality of life, while the association between internalized stigma and adherence was mediated by the use of stigma-avoidant coping strategies, suggesting that keeping one's diagnosis a secret may make it more difficult to take one's medications. These findings suggest that these women constitute a vulnerable population who need additional services to optimize their health and who might benefit from peer support interventions and stigma-reduction programs for family and community members.

Relationships Among Adherence and Physical and Mental Health Among Women Living with HIV in Rural India

We conducted a cross-sectional examination of the physical and psychological factors related to ART adherence among a sample of 400 women living with HIV/AIDS in rural India. Interviewer-administered measures assessed adherence, internalized stigma, depressive symptoms, quality of life, food insecurity, health history and sociodemographic information. CD4 counts were measured using blood collected at screening. Findings revealed that adherence to ART was generally low, with 94% of women taking 50% or less of prescribed medication in past month. Multivariate analyses showed a non-linear association between numbers of self-reported opportunistic infections (OIs) in past 6 months (p = 0.016) and adherence, with adherence decreasing with each additional OI for 0-5 OIs. For those reporting more than 5 OIs, the association reversed direction, with increasing OIs beyond 5 associated with greater adherence.

Quality of Life Among Women Living With HIV in Rural India

A cross-sectional examination was conducted on quality of life (QOL) among women living with HIV (WLWH) in rural Andhra Pradesh, India. Baseline data were collected from 400 WLWH and their children. QOL was measured with 10 items from the Quality of Life Enjoyment and Satisfaction Questionnaire. Findings revealed low QOL scores; on a scale from 0 to 3, the mean QOL score was 0.38 (SD = 0.30). Depression symptoms were reported by 25.5%, internalized stigma was high, and most reported little to no social support. Multivariable analysis revealed positive associations between QOL and CD4+ T cells (b = .0011, p = .021) and social support (b = .260, p < .0001), and a negative relationship between QOL and internalized stigma (b = -.232, p < .0001). Interventions focused on improving QOL for WLWH should incorporate strategies to improve social support and adherence to antiretroviral therapy, while mitigating internalized stigma.

Differences in testing, stigma, and perceived consequences of stigmatization among heterosexual men and women living with HIV in Bengaluru, India

Approximately 2.4 million people in India are living with HIV. Gender inequality affects HIV prevention, detection, and management. The purpose of this paper was to describe gender differences in the experience of living with HIV in Bengaluru, India. A subsample of n = 313 (159 men and 154 women) from a larger cohort was used for these analyses. Participants were recruited through AIDS service organizations. They completed an interviewer-administered survey assessing HIV testing experience, types of stigma, and perceived consequences of stigmatization. The majority of men (67%) reported getting HIV tested because of illness, while women were more likely to be tested after learning their spouse's HIV-positive status (42%). More men (59%) than women (45%, p<0.05) were tested in private care settings. Men reported significantly higher mean levels of internalized stigma (men: M=0.71, SD = 0.63; women: M=0.46, SD = 0.55; p<0.001), whereas the women reported significantly higher scores for enacted stigma (men: M=1.30, SD = 1.69; women: M=2.10, SD = 2.17; p<0.001). These differences remained significant after controlling for potential socio-demographic covariates. Following their diagnosis, more women reported moving out of their homes (men: 16%; women: 26%; p<0.05). More men (89%) than women (66%; p<0.001) reported to have modified their sexual behavior after being diagnosed. These findings suggest that the experience of living with HIV and HIV stigma varies by gender in this population. Suggestions for a gender-based approach to HIV prevention and stigma reduction are provided.

Physical and mental health of rural southern Indian women living with AIDS

The purpose of this descriptive study is to highlight the physical and mental health symptoms of 68 rural women living with AIDS (WLA) in India, their compliance to antiretroviral therapy (ART) medication, and barriers to accessing health care within the past 6 months. Physical and mental health status was obtained by self-report, administered by questionnaire and physician-determined clinical assessment, as well as selected objective parameters. Findings revealed that while rural WLA had been on antiretroviral therapy for just under 2 years, they self-reported a high prevalence of physical symptoms, and more than half reported high levels of depressive symptoms and major barriers to accessing health care. CD4 levels, body weight, and basal metabolic rate were also low. While the rural and urban WLA faced similar health care challenges, the demographic characteristics of the rural women may make them more vulnerable, as they are less adherent to ART and slimmer than their urban counterparts.

Correlates of Adherence among Rural Indian Women Living with HIV/AIDS

In this prospective, randomized clinical trial, correlates of adherence to antiretroviral therapy (ART) were assessed using a baseline questionnaire among 68 rural women living with AIDS (WLA) in India. Unadjusted analyses revealed positive relationships of ART adherence with Hindu religion, and support from spouses and parents, whereas negative associations were found with depression, poor quality of life, and having ten or more HIV symptoms. Multiple linear regression analysis also revealed that WLA who were Hindu, not depressed, had ART support from spouses and parents, and perceived some benefit from ART were more adherent to ART than their respective counterparts. This study reveals the unique challenges which rural WLA experience and the need to mitigate these challenges early in ART treatment. Further, the findings enable the refinement of an intervention program which will focus on strengthening ART adherence among rural WLA.

Correlates of depression among rural women living with AIDS in Southern India

Although depression may be commonly experienced by persons living with AIDS, it may be challenging for health care providers to identify persons who are suffering from depression symptoms, particularly if they are living in the more isolated rural areas of India. The purpose of this study is to assess correlates of depression among women living with AIDS in rural Andhra Pradesh, India. A total of 68 rural women living with AIDS (WLA) completed baseline data and were assessed by means of structured instruments. Regression modeling revealed that disclosure avoidance and making at least six health care visits in the last six months were all associated with depression. Further, living with a spouse was associated with lower depressive symptom scores. Stigma was not found to be associated with depression. Understanding correlates of depression can lead the way toward designing culturally-tailored interventions that can mitigate disclosure avoidance and improve the health of women. A more comprehensive health focus may be needed to empower the women to seek quality care for both physical health, as well as mental health, symptomatology.