Stigma in HIV‐Positive Women

HIV and vicarious stigma in a cohort of people living with HIV in Italy: What happens when the stigma is fueled by healthcare providers?

Vicarious stigma shows how indirect stigmatizing experiences can lead people living with HIV (PLWH) to feel discriminated against. We enrolled 350 PLWH, who were administered a 17-item questionnaire to investigate a subjective experience of stigma experienced in the hospital care setting. We found that at least once 215 PLWH (61.4%) did not want the HIV exemption indicated on the prescription for a specialist medical visit, 232 PLWH (66.3%) never used their HIV-related exemption to make a specialist medical visit, 230 PLWH (65.7%) avoided undergoing a medical assessment outside the infectious disease clinics and 241 patients (68.9%) felt unwelcome during a specialist medical visit. Moreover, 241 patients (61.1%) had heard at least once stories of health workers who did not want to touch PLWH, 213 patients (60.9%) had heard stories at least once of PLWH who had been mistreated by hospital staff, 180 patients (51.4%) had at least once heard stories about PLWH being refused treatment and services and 257 patients (73.4%) had at least once heard stories about health workers talking publicly about PLWH. This is a little explored area, especially regarding the vicarious stigma faced by PLWH. Our findings indicate the importance of combating HIV-related stigma for the wellbeing of PLWH.

Experiences of Stigmatization and Discrimination in Accessing Health Care Services Among People Living with HIV (PLHIV) in Akwa Ibom State, Nigeria

Background

Recent advances in care and treatment have turned HIV into a "chronic but manageable condition". Despite this, some people living with HIV (PLHIV) continue to suffer from stigma and discrimination in accessing health care services. This study examined the experience of stigma and discrimination and access to health care services among PLHIV in Akwa Ibom State.

Methods

The Center for Clinical Care and Clinical Research (CCCRN), implementing a USAID-funded Integrated Child Health and Social Services Award (ICHSSA 1) project, conducted a community-based cross-sectional survey in 12 randomly selected local government areas in Akwa Ibom State, Nigeria. A structured quantitative questionnaire was used for data collection. In total, 425 randomly selected PLHIV were interviewed after providing informed consent. Descriptive statistics and bivariate analyses were conducted using the data analytical application Stata 14.

Results

The study revealed that 215 PLHIV (50.4%) had been denied access to health care services, including dental care, because of their HIV status in Akwa Ibom State. Respondents reported being afraid of: gossip (78%), being verbally abused (17%), or being physically harassed or assaulted because of their positive status (13%). Self-stigmatization was also evident; respondents reported being ashamed because of their positive HIV status (29%), exhibiting self-guilt (16%), having low self-esteem (38%), and experiencing self-isolation (36%). Women, rural residents, PLHIV with no education, unemployed, single, young people aged between 19 and 29 years, and older adults were more likely to experience HIV-related stigmatization.

Conclusion

Data from the study revealed that the percentage of PLHIV who experience health-related stigmatization because of their HIV status is high in Akwa Ibom State. This finding calls for the prioritization of interventions to reduce stigma, enhance self-esteem, and promote empathy and compassion for PLHIV. It also highlights the need for HIV education for family and community members and health care providers, to enhance the knowledge of HIV and improve acceptance of PLHIV within families, communities, and health care settings.

Relationships Between Stigma and Intimate Partner Violence Among Female Sex Workers Living With HIV: Social and Economic Exclusion

Violence against female sex workers (FSWs) perpetrated by their intimate (i.e., non-commercial) partners, particularly against FSWs living with HIV, is understudied. Stigma can deplete the economic resources, social relationships, and mental well-being of stigmatized people, which may increase their intimate partner violence (IPV) risk. We quantitatively assessed relationships between HIV stigma and sex work stigma and IPV victimization among FSWs living with HIV in the Dominican Republic (n = 266). Enacted HIV stigma, in the form of job loss, and anticipated HIV stigma, in the form of fear of exclusion by family, were associated with increased IPV risk. Potential association mechanisms, including increased economic vulnerability and social isolation, and programmatic responses are discussed.

A qualitative metasynthesis of stigma in women living with HIV in the United States

Our goal was to synthesize qualitative studies on HIV-related stigma as experienced by women living with HIV (WLWH) in the U.S. Qualitative metasynthesis techniques as developed by Sandelowski et al. (Res Nurs Health 30(1):99-111, 2007) were used to integrate and update findings on stigma in WLWH in the U.S. in 43 reports of qualitative studies conducted between 2004 and 2023 with 1118 participants. Developed themes explored a collective narrative of women first surviving the intersectionality of multiple sources of stigma, discovering non-linear pathways to transcend their stigma, and finally experiencing resilience through their transcendence of stigma. While this metasynthesis revealed similarities to an earlier metasynthesis in the ubiquity and persistence of stigma, they differ primarily in women's abilities to find agency in managing and opposing their stigma. This cognitive reframing of their stigma helped women to redefine stigma as ignorance and move towards a more positive assessment of the self. In doing so, they separated themselves from their stigma and the damaging effects of it. Findings from this metasynthesis may serve as a useful tool for the development of stigma reduction interventions specific to the needs and experiences of WLWH in the U.S.

A qualitative analysis examining intersectional stigma among young adults living with HIV in Atlanta, Georgia

HIV-related stigma is a barrier to engagement in care for young adults living with HIV. Other intersecting forms of stigma (e.g., racism, sexism, homophobia), may worsen HIV-related stigma and impact engagement in care. From November 2020 to February 2021, we conducted 20 in-depth qualitative interviews among young adults living with HIV attending a large, comprehensive HIV care center in Atlanta, Georgia. Semi-structured interview guides based on Earnshaw and Chaudoir's HIV Stigma Framework and the theory of intersectionality facilitated discussion around experiences with various forms of stigma and its possible influence on healthcare engagement. Using the social-ecological model, we used thematic analysis to contextualize how young adults living with HIV experienced intersectional stigma and enacted, anticipated, and internalized HIV stigma in both healthcare and non-healthcare settings. Most participants identified as male, Black/African American, and gay. Participants described stigma at intrapersonal, interpersonal, clinic, and community levels. Intrapersonal stigma was associated with delayed care seeking, isolation, and fear of disclosure. Interpersonal stigma included discrimination from family and friends and avoidance of close relationships to elude disclosure. At the clinic level, stigma included negative experiences with staff in HIV and non-HIV healthcare settings, which contributed to decreased engagement in care. Stigma in the community included differential treatment from employers, community leaders, and religious community and was associated with feelings of helplessness related to current societal inequalities. Coping/motivating mechanisms for stigma included prioritizing health, eliciting support from the medical care team and peers. Our findings show different intersecting stigmas are barriers to healthcare at multiple levels for young adults living with HIV, potentially exacerbating existing health and social disparities. To improve engagement in care among young adults living with HIV, future interventions should address the different mechanisms of stigma at community, clinic, interpersonal and intrapersonal levels by enhancing social support and improving healthcare structural competency.

A qualitative inquiry of experiences of HIV-related stigma and its effects among people living with HIV on treatment in rural Kilifi, Kenya

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.

Reducing stigma towards people living with HIV and people who inject drugs using social norms theory: An online study with Australian health care workers

BACKGROUND

Despite extensive evidence regarding the negative effects of stigma experienced by people living with HIV (PLHIV) and people who inject drugs within health care settings, comparatively little evidence exists regarding the effectiveness of initiatives to reduce this stigma.

METHOD

This study developed and assessed brief online interventions based on social norms theory with a sample of Australian health care workers (n=653). Participants were randomly allocated to either 1) HIV intervention group, or 2) injecting drug use intervention group. They completed baseline measures of their attitudes towards either PLHIV or people who inject drugs, matching measures of their perceptions of their colleagues' attitudes, plus a series of items reflecting behavioural intentions and agreement with stigmatising behaviour towards PLHIV or people who inject drugs. Participants were presented with a social norms video before completing the measures again.

RESULTS

At baseline, participants' agreement with stigmatising behaviour was correlated with their perceptions of how many of their colleagues would agree. After watching the video, participants reported more positive perceptions of their colleagues' attitudes towards PLHIV and people who inject drugs, as well as more positive personal attitudes towards people who inject drugs. Changes in perceptions of colleagues' support for stigmatising behaviour independently predicted changes in participants' personal agreement with that behaviour.

CONCLUSION

Findings suggest that interventions based on social norms theory that address health care workers' perceptions of their colleagues' attitudes can play an important role in contributing to broader initiatives to reduce stigma in health care settings.

Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

A Retrospective Cohort Study of Women and Men Living with HIV, Attending an HIV Clinic in Australia

OBJECTIVES

To compare women with men presenting with HIV to a public health HIV clinic, to identify the special characteristics and health care needs of women living with HIV in the Barwon South West region in Victoria.

METHODS

A retrospective cohort study of 35 women and 135 men living with HIV who attended the clinic between 2009 and 2020. Gender differences were assessed using nonparametric analyses.

RESULTS

The women were diagnosed with HIV younger than the men (mean 29.5 years vs. 36.7 years) and more were born in Africa (28.6% vs. 5.2%). More men than women presented with sexually transmittable infections (38.5% vs. 14.3%) at the time of diagnosis, and were diagnosed through a sexual health screen (37% vs. 17%). The proportions of men and women who used alcohol and other drugs (recent to their diagnosis) were similar (68.1% vs. 48.6%), and there was no difference in proportions presenting with AIDS-defining illnesses (p = 0.425), or CD4 cell count (advanced: ≤200 cells, relatively well: ≥201 cells, p = 0.241), but the women had a lower viral load (p < 0.001).

CONCLUSIONS

In this study of 170 people living with HIV, nearly one-half of the men with known HIV history were diagnosed through sexual health screens, but women's HIV was mostly detected through targeted screening. Results highlight gender disparity in access to sexual health screening and assessment, including low awareness of sexual health risks for women, and endorse the view that HIV is a heterosexual sexually transmittable infection in women.

Dehumanizing language, motherhood in the context of HIV, and overcoming HIV stigma - the voices of Rwandan women with HIV: A focus group study

BACKGROUND

Stigma is an underlying cause of health inequities, and a major barrier to HIV prevention, care, and treatment. Experiences of HIV stigma have been shown to reduce engagement in care across the HIV care continuum, from testing and diagnosis to long-term retention in care and anti-retroviral therapy adherence. In Rwanda, approximately 130,000 women are living with HIV, representing a prevalence rate (3.7%) which is substantially higher than Rwandan men (2.2%). Both the national Rwanda and City of Kigali HIV and AIDS strategic plans identify stigma as a key concern for reducing the burden of HIV.

OBJECTIVES

The first objective of this study was to understand the sources of HIV-related stigma among women living with HIV in Rwanda. The second objective was to understand the cultural, linguistic, and contextual context of HIV-related stigma and the intersection of HIV-related stigma to the HIV care continuum (engagement in care, medication/treatment adherence) among women with HIV in Rwanda.

DESIGN

This study used a cross-sectional, qualitative design.

SETTING AND PARTICIPANTS

Three-three women from urban and rural settings in Rwanda were recruited from public HIV treatment and care centers to participate in this study.

METHOD

Focus groups discussions, guided by a structured interview guide, were used to collect qualitative data. Framework analysis was used to analyze the data, which was collected during July 2018.

RESULTS

The participants in this study highlighted that Rwandan women with HIV experience all forms of stigma - enacted, anticipated, perceived, and internalized - associated with HIV as well as structural stigma. Further, three major themes - dehumanizing language, importance of motherhood in the context of HIV, and overcoming HIV stigma - emerged from the data.

CONCLUSION

The results of this study are among the few to give voice and perspective to the stigma experiences of Rwandan women with HIV. The women with HIV participating in this study shed light on the pervasive and culturally constructed effects of stigma that continue to exist. Further, the findings from this study highlighted the significant intersection of the role dehumanizing language experienced by Rwandan women with HIV. Additionally, the intersectional identities of being a woman with HIV and a mother and their relationship to societal and cultural norms and expectations must be considered concurrently. Finally, the beneficial effects of support groups was identified as key in helping Rwandan women with HIV to accept self.

COVID-19 related stigma, empathy and intention for testing in Jordan

Stigmatization of COVID-19 disease has been speculated due to misinformation about the disease, fearing of contracting the infection, absence of available cure, and holding responsibility for infecting others. We aimed to establish the prevalence of COVID-19 related stigma and its association with empathic responding, in addition to exploring predictors of stigma and testing intention among Jordanian people. A quantitative, descriptive and predictive design was used and data were collected using a web-based survey from 1074 adults. Findings showed that participants had high stigmatization against COVID-19 infection. Higher empathic responding (both cognitive and affective), being a female participant, and older age resulted in higher stigmatization. Only stigmatization of COVID-19 negatively predicted individuals’ intention for testing. These findings warrant intensive efforts from the Jordanian government on a local and national level to provide ongoing public education related to several aspects of COVID-19 disease, in order to reduce or prevent the associated stigma and increase people’s intention for testing.

Sexuality-Based Stigma and Access to Care: Intersecting Perspectives Between Health Care Providers and Men Who Have Sex With Men in HIV Care Centres in Senegal

Men who have sex with men (MSM) in Senegal face a challenging socio-legal context, marked by homophobia and the illegality of homosexuality. In addition, human immunodeficiency virus (HIV) prevalence among MSM is 27.6%, 46 times greater than the one in the general population (0.5%). Nevertheless, access to healthcare by MSM may be hampered by stigmatizing attitudes from health facility staff (medical and non-medical). This article describes the health facility staff/MSM relationship and analyses its effects on access to healthcare by MSM. The data used were collected through a field survey based on observations and qualitative interviews conducted in 2019 and 2020 with 16 MSM, 1 non-governmental organization (NGO) staff and 9 healthcare providers in Dakar (the capital city) and Mbour (secondary city on the West Coast) hospitals. The data were subject to a thematic analysis assisted by the ATLAS software. The relationship between MSM and healthcare providers is ambiguous. On the one hand, healthcare providers are torn between their professional duty to treat MSM and the cost of being stigmatized by other colleagues. Therefore, they often limit their empathy with MSM within the hospital context. On the other hand, MSM, trusting in the confidentiality of healthcare providers, feel safe in the care pathway. However, we identify the following stigmatizing factors limiting access to care include (1) fear of meeting a relative, (2) difficult relationships with non-medical support staff (mainly security guards), (3) HIV status disclosure and (4) potential conflicts with other MSM. This study is unique as it includes non-medical staff in its respondents. It shows that hospitals are divided into several areas, based on the stigma perceived by MSM. It is important to map out MSM’s care trajectories and spaces and to identify all types of staff working within them, including non-medical staff, and enrol them in stigma reduction interventions.

HIV-Related Internalized Stigma and Patient Health Engagement Model in an Italian Cohort of People Living With HIV

The care engagement of people living with HIV (PLWH) measured with the patient health engagement (PHE) model and its association with HIV-related internalized stigma are not well established. Indeed, currently there are no data yet about the engagement of PLWH measured with the PHE model. This study aimed to evaluate the effects of HIV-related internalized stigma on care engagement and mental health and to fill the lack of data on PHE model applied to PLWH. We found that the internalized stigma score was significantly higher for PLWH (n=82) in worse care engagement phase and both higher internalized stigma scores and worse engagement were associated to major depression symptoms.In conclusion, our findings describe for the first time the engagement in care of PLWH measured with PHE and highlight the importance of PLWH support to find strategies to cope stigma-related stress and optimize their care engagement.

‘The spiral just keeps on going’: Cascading health and social issues for women living and aging with HIV

Background:

There has been limited qualitative inquiry aimed at understanding the gendered and unique experiences of women living with HIV in high-income countries. In Australia, the relatively small number of women living with HIV means they have been largely overlooked in social, clinical, and policy representations of HIV over time.

Objectives:

To explore the experiences of women living long-term and aging with HIV, to understand the complex intersections between their health and social trajectories.

Methods:

Data were collected as part of Living Positive in Queensland, a longitudinal qualitative study of the experiences of living long-term and aging of people living with HIV in Queensland, Australia. This study analysed data from three annual, semi-structured interviews with the 11 female participants.

Results:

Women negotiated gendered roles and identities as they grappled with ongoing and intertwined health and psychosocial challenges over their life course. Development of co-morbidities, experiences of stigma, gendered social roles, financial precarity, and limited social support amplified the challenges of living with HIV and cumulatively impacted women’s health and wellbeing as they aged with HIV.

Conclusion:

The health and wellbeing of women living with HIV are adversely impacted by intersecting complex health issues, HIV-related stigma, gendered identities, social disadvantage, and aging. Greater attention to the unique needs of women living with HIV is necessary to reduce the prevalence of psychological distress, financial stress, and vulnerability to social isolation which, in turn, lead to poorer health.

Sex Differences in Non-AIDS Comorbidities Among People With Human Immunodeficiency Virus

Women are grossly underrepresented in human immunodeficiency virus (HIV) clinical and translational research. This is concerning given that people with HIV (PWH) are living longer, and thus accumulating aging-related non-AIDS comorbidities (NACMs); emerging evidence suggests that women are at higher risk of NACM development and progression compared with men. It is widely recognized that women vs men have greater immune activation in response to many viruses, including HIV-1; this likely influences sex-differential NACM development related to differences in HIV-associated chronic inflammation. Furthermore, many sociobehavioral factors that contribute to aging-related NACMs are known to differ by sex. The objectives of this review were to (1) synthesize sex-stratified data on 4 NACMs among PWH: bone disease, cardiovascular disease, metabolic dysfunction, and neurocognitive impairment; (2) evaluate the characteristics of key studies assessing sex differences in NACMs; and (3) introduce potential biological and psychosocial mechanisms contributing to emerging trends in sex-differential NACM risk and outcomes among PWH.

Older Adults Vastly Overestimate Both HIV Acquisition Risk and HIV Prevalence in Rural South Africa

Perceptions of HIV acquisition risk and prevalence shape sexual behavior in sub-Saharan Africa (SSA). We used data from the Health and Aging in Africa: A Longitudinal Study of an INDEPTH Community in South Africa baseline survey. Data were collected through home-based interviews of 5059 people ≥ 40 years old. We elicited information on perceived risk of HIV acquisition and HIV prevalence among adults  ≥ 15 and ≥ 50 years old. We first describe these perceptions in key subgroups and then compared them to actual estimates for this cohort. We then evaluated the relationship between sociodemographic characteristics and accurate perceptions of prevalence in regression models. Finally, we explored differences in behavioral characteristics among those who overestimated risk compared to those who underestimated or accurately estimated risk. Compared to the actual HIV acquisition risk of < 1%, respondents vastly overestimated this risk: 35% (95% CI: 32-37) and 34% (95% CI: 32-36) for men and women, respectively. Respondents overestimated HIV prevalence at 53% (95% CI: 52-53) for those ≥ 15 years old and 48% (95% CI: 48-49) for those ≥ 50 years old. True values were less than half of these estimates. There were few significant associations between demographic characteristics and accuracy. Finally, high overestimators of HIV prevalence tested themselves less for HIV compared to mild overestimators and accurate reporters. More than 30 years into the HIV epidemic, older people in a community with hyperendemic HIV in SSA vastly overestimate both HIV acquisition risk and prevalence. These misperceptions may lead to fatalism and reduced motivation for prevention efforts, possibly explaining the continued high HIV incidence in this community.

Enduring stigma and precarity: A review of qualitative research examining the experiences of women living with HIV in high income countries over two decades

The lived experience of HIV for women remains poorly understood. In particular, there has been little attention to the consequences for women living with HIV (WLHIV) of changing social, epidemiological, biomedical and policy contexts, or to the implications of long-term treatment and aging for the current generation of HIV-positive women. We reviewed qualitative research with WLHIV in selected high-income countries (Australia, Canada, New Zealand, the UK and the USA) to identify the most prevalent experiences of HIV for women and trends over time. Our synthesis highlights the relative consistency of experiences of a diverse sample of WLHIV, particularly the enduring prevalence of gendered HIV-related stigma, sociostructural barriers to healthcare and support, and negative encounters with health professionals. We also identified gaps in knowledge. Understanding women's experiences, particularly their changing needs and strategies for coping as they live long-term with HIV, is key to effective support and services for WLHIV.

Successful Smoking Cessation among Women Smokers Based on Utilizing National Smoking Cessation Service Type in Korea

Background: This study aimed to evaluate the successful smoking cessation across different national smoking cessation services. Methods: This study included data that had been previously entered into the integrated information system for smoking cessation services and comprised 144,688 participants after excluding missing data. These clinics provide face-to-face counseling, phone calls, text messages, and e-mail services for six months and nine sessions. Results: The women-only program had the lowest success rate (11.3%). Compared with the women-only program, the six-month success rate of smoking cessation clinic at public health centers (OR = 3.72, CI = [3.52, 3.92]), visiting-type smoking cessation clinics (OR = 2.97, CI = [2.79, 3.16]), the residential 4 -night 5-day program (OR = 7.79, CI = [6.49, 9.35]), and a program for inpatients (OR = 2.36, CI = [1.89, 2.94]) showed a significant increase. Conclusions: Emotional labor workers who participated in the women-only program had low smoking cessation success rates, while those who participated in the residential 4-night 5-day program had high success rates.

Prevalence and Correlates of HIV Stigma Among Women Living with HIV in Metro Vancouver, Canada

This study elucidated the prevalence and correlates of four types of HIV stigma among women living with HIV (WLWH). Data were drawn from 2 years (September 1/15 to August 31/17) of follow-up from a longitudinal community-based open cohort of 215 cisgender or transgender WLWH who lived and/or accessed care in Metro Vancouver, Canada (2014-present). Bivariate and multivariable cumulative logistic regression using generalized estimating equations for repeated measures were used to examine correlates of HIV stigma, including: (1) anticipated; (2) enacted; (3) internalized; and (4) perceived stigma. In multivariable analysis, disclosure of HIV status without consent was significantly associated with heightened: anticipated; enacted; and perceived stigma. Verbal and/or physical violence related to HIV status was significantly associated with heightened enacted, internalized and perceived stigma. Negative physical effects/symptoms of HIV was significantly associated with all stigma outcomes. Results suggest a need to support safe disclosure of HIV status and address social and structural violence against WLWH.

Online interventions to reduce stigma towards population groups affected by blood borne viruses in Australia

BACKGROUND

Stigmatising attitudes and behaviours by others can have a range of negative effects for population groups and individual people affected by blood borne viruses. The reduction of stigma is a major goal within current Australian national health strategies, however, there is a lack of evidence regarding effective interventions to achieve this goal. Drawing on Allport's (1954) intergroup contact theory, this study aimed to evaluate the effectiveness of an online stigma reduction intervention implemented with the Australian public.

METHODS

The study was conducted between February and May 2020. Australian adults recruited via Facebook advertising were randomly allocated to a control group (n=316) or one of five intervention groups: people living with HIV (n=320), people living with hepatitis C (n=347), people living with hepatitis B (n=333), people who inject drugs (n=316), or sex workers (n=296). Participants viewed a short video depicting lived experiences of their assigned group. Participants completed attitudinal measures about the group before and immediately after the video, and then at three-month follow-up. These measures related to overall attitudes towards the group, controllability of the stigmatised condition/behaviour, desire to maintain personal distance from the group, and opinions regarding treatment of the group in health care and public policy. Longitudinal changes in attitudes were analysed using a mixed effects regression model with maximum likelihood estimation.

RESULTS

Across each of the intervention groups, reductions in negative attitudes were found immediately after watching the videos on almost all outcome measures. By three-month follow-up, the HIV intervention group demonstrated long-term improvements in relation to personal distance compared to the control group, and the hepatitis B intervention group demonstrated long-term improvements in relation to attitudes and personal distance compared to the control group. Across intervention and control groups, long-term reductions in negative attitudes were found in relation to HIV controllability, hepatitis B controllability and opinions, hepatitis C controllability and opinions, and injecting drug use attitudes and opinions.

CONCLUSION

Brief online videos depicting priority populations groups demonstrated positive results in terms of reducing some stigmatising attitudes towards those groups amongst members of the Australian public. Online contact interventions have the potential to be scaled up and rolled out across jurisdictions at national and international levels. These findings suggest that these interventions could be an effective way to contribute to the reduction of stigma and discrimination towards populations affected by blood borne viruses.

HIV-related stigma and health-related quality of life in women living with HIV in developed countries: a systematic review

HIV-related stigma has been shown to negatively affect the health-related quality of life (HRQoL) in people living with HIV. Women living with HIV (WLWH) suffer greater consequences from stigma on multiple health outcomes when compared to men. The objective of this review was to examine the association between HIV-related stigma and HRQoL in WLWH in developed countries. A systematic search was conducted in three medical databases. The PRISMA guideline was used as a methodical frame of reference, and the STROBE checklist as a quality assessment tool. Eight studies on a total of 2903 WLWH were included. All studies were cross-sectional of design and published between 2011-2019. All studies found a negative and statistically significant association between HIV-related stigma and HRQoL. The association was found to be weak to moderate in strength when examined using correlations statistics. Heterogeneity across the choice of measures and variables examined in the included studies made comparison difficult. Risk of bias was deemed present in majority of studies. Thus, this review reveals a negative association between HIV-related stigma and HRQoL in WLWH in developed countries. The association appears to be influenced by a range of complex factors, such as psychosocial variables and sociodemographic determinants.

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

Aim and objectives

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

Design

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

Method

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

Results

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

Conclusion

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

Intersectionality and health-related stigma: insights from experiences of people living with stigmatized health conditions in Indonesia

Background

Health-related stigma is a complex phenomenon, the experience of which intersects with those of other adversities arising from a diversity of social inequalities and oppressive identities like gender, sexuality, and poverty – a concept called “intersectionality”. Understanding this intersectionality between health-related stigma and other forms of social marginalization can provide a fuller and more comprehensive picture of stigma associated with health conditions. The main objective of this paper is to build upon the concept of intersectionality in health-related stigma by exploring the convergence of experiences of stigma and other adversities across the intersections of health and other forms of social oppressions among people living with stigmatized health conditions in Indonesia.

Methods

This qualitative study interviewed 40 people affected by either of four stigmatizing health conditions (HIV, leprosy, schizophrenia, and diabetes) in Jakarta and West Java, Indonesia between March and June 2018. Data was analyzed thematically using an integrative inductive-deductive framework approach.

Results

The main intersectional inequalities identified by the participants were gender and socioeconomic status (n = 21), followed by religion (n = 13), age (n = 11), co-morbidity (n = 9), disability (n = 6), and sexuality (n = 4). Based on these inequalities/identities, the participants reported of experiencing oppression because of prevailing social norms, systems, and policies (macro-level), exclusion and discrimination from societal actors (meso-level), and self-shame and stigma (micro-level). While religion and age posed adversities that negatively affected participants in macro and meso levels, they helped mitigate the negative experiences of stigma in micro level by improving self-acceptance and self-confidence.

Conclusion

This study uncovered how the experience of health-related stigma intersects with other oppressions originating from the various social inequalities in an individual’s life. The findings highlight the importance of acknowledging and understanding the multi-dimensional aspect of lives of people living with stigmatized health conditions, and warrant integrated multi-level and cross-cutting stigma reduction interventions to address the intersectional oppressions they experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-020-01318-w.

Youth living with HIV/AIDS in secondary schools: perspectives of peer educators and patron teachers in Western Uganda on stressors and supports

As Youth Living With HIV/AIDS (YLWHA) continue to survive and live with HIV chronically due to effective Antiretroviral Therapy (ART), it is paramount to work toward maximising their psychosocial wellbeing. The school where these YLWHA are expected to spend most of their time is an excellent environment to investigate this. In this study, we explore perspectives of Peer Educators (PEs) in secondary schools of one district in Western Uganda on how YLWHA are perceived in school, on their daily stressors and their way of coping with their HIV-positive serostatus given the support of the schools. We conducted eight focus groups with a total of 59 students who were members of Peer Educators Clubs (PECs) as well as 8 in-depth interviews with patron teachers of PECs in eight secondary schools of Kabarole district, selected through a stratified random sampling method. Focus groups and interviews were tape-recorded, transcribed and analysed thematically both inductively and deductively. Stressors and support in schools, as identified by the PEs were categorised into three interrelated thematic domains; psychological wellbeing of YLWHA, disclosure of HIV status by YLWHA, and health and treatment adherence. Stigma was found to be a key stressor and an intermediary in all the three thematic domains Stressors affecting psychological wellbeing were fear of death and uncertainty of the future compounded by financial and academic challenges. Stressors affecting disclosure centred around lack of privacy, confidentiality and fear of loss of friends. Stressors affecting treatment adherence included lack of privacy while taking drugs, unintended disclosure while obtaining drugs or seeking permission to attend clinic appointments and fear of drug adverse effects due to poor nutrition. A supportive school environment involved the availability of a school nurse, counselling services and PECs. We conclude that the school environment brings more stressors than supports for YLWHA. The daily stressors related to HIV stigma, uncertainty, disclosure, privacy and confidentiality render schooling a hassle for YLWHA. Interventions that promote resilient school communities are necessary to foster disclosure in a non-discriminatory and stigma-free environment. This calls for concerted efforts from all school stakeholders.

HIV testing intentions and cognitive reappraisal among Latino emerging adults

Negative emotions related to HIV testing may influence an individual's intentions to test for HIV. However, emotion regulation strategies such as cognitive reappraisal which involves reframing the meaning of an event to modify one's emotional response to it may potentially help to regulate these emotions and facilitate decisions to get tested for HIV. In this exploratory study, we examined the association between cognitive reappraisal and HIV testing intentions and whether this association differs by gender. Cross-sectional data were collected from a convenience sample of 157 Latino emerging adults aged 18-25 years living in Arizona and Florida through an online survey. Hierarchical logistic regression models were used to analyze the data. Results indicated that cognitive reappraisal was significantly associated with HIV testing intentions (aOR: 1.44, 95% CI:1.04-1.99) and that this association was specific to females (aOR: 2.48, 95% CI: 1.39-4.43). Our results demonstrate the potential of cognitive reappraisal to facilitate HIV testing intentions among females. HIV prevention interventions should incorporate cognitive reappraisal training to regulate and adapt to the negative emotions associated with HIV testing in efforts to increase HIV testing.

Experiences and Attitudes of People with HIV/AIDS: A Systematic Review of Qualitative Studies

The aim of this article was to explore the experiences and attitudes of people with HIV/AIDS. A systematic review of qualitative studies was carried out. Twenty-seven articles were included, with sample sizes ranging from 3 to 78. Articles from North America, South America, Central America, Europe, and Africa were included. Five topics emerged from the synthesis: feelings about the diagnosis of HIV/AIDS; stigma and HIV/AIDS; changes in sexual behavior after becoming infected; living with the virus; and pregnancy and motherhood in seropositive women. The moment of diagnosis is of vital importance for these people due to feelings such as disappointment, sadness, fear, despair, lack of awareness, and pain. Social support is highly valued among these people and is linked to an improvement in these peoples’ quality of life. Different kinds of stigma accompany people with HIV/AIDS throughout their life, like social stigma, self-stigma, and health professionals’ stigma. Seropositive women who decide to become mothers can feel frustration because they cannot breastfeed. Spirituality helps some people to deal with the fact of being a virus or disease carrier.

Gender, HIV-Related Stigma, and Health-Related Quality of Life Among Adults Enrolling in HIV Care in Tanzania

HIV-related stigma has been associated with worse health-related quality of life (HRQoL) among people living with HIV (PLWH). Little is known about how different types of HIV-related stigma (i.e., anticipatory, internalized, or enacted HIV-related stigma) influence HRQoL and whether these relationships differ by gender. The sample included 912 PLWH aged 18 years or older enrolling in HIV care at four health facilities in Tanzania. HRQoL was assessed with the life satisfaction and overall function subscales of the HIV/AIDS-Targeted Quality of Life (HAT-QoL) instrument. Sex-stratified multivariable logistic regression modeled the association of anticipatory, internalized, and enacted HIV-related stigma on poor HRQoL. Across all participants, the mean life satisfaction score was 63.4 (IQR: 43.8, 81.3) and the mean overall function score was 72.0 (IQR: 58.3, 91.7). Mean HRQoL scores were significantly higher for women compared to men for overall function (5.1 points higher) and life satisfaction (4.3 points higher). Fourteen percent of respondents reported recent enacted HIV-related stigma and 13% reported recent medium or high levels of internalized stigma. In multivariable models, high internalized and high anticipatory stigma were significantly associated with higher odds of poor life satisfaction and poor overall function in both men and women. Psychosocial interventions to prevent or reduce the impact of internalized and anticipatory stigma may improve HRQoL among persons in HIV care. Future research should longitudinally examine mechanisms between HIV-related stigma, poor HRQoL, and HIV care outcomes.

The relationship between stigma and a rehabilitation framework [international classification of functioning, disability and health (ICF)]: three case studies of women living with HIV in Lusaka, Zambia

PURPOSE

To explore how the International Classification of Functioning, Disability and Health, a rehabilitation framework, can provide a holistic understanding of stigma experiences of three women living with human immunodeficiency virus in Lusaka, Zambia.

METHODS

A secondary analysis of three cases by drawing on interview transcripts collected as part of a larger longitudinal study with eighteen women living with the virus. The interview tool used the rehabilitation framework to ask questions about the impact of the virus on the body, daily activities, social participation and the future. Vignettes were produced for each of the eighteen women including information on stigma and the rehabilitation framework. Three case studies were developed from women who provided comprehensive accounts of stigma and the International Classification of Functioning, Disability and Health.

RESULTS

Stigma experiences aligned well with three dimensions of the International Classification of Functioning, Disability and Health: participation restrictions, environmental and personal factors. These domains were used to understand stigma in three forms (i.e. enacted, self and structural stigma) as experienced by these women.

CONCLUSIONS

More research is needed to ascertain how stigma and rehabilitation are related in other environments and populations and to explore how to mitigate stigma within the rehabilitation context.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals deal with aspects of stigma and discrimination in their clinical work and this analysis offers a way to consider HIV-related stigma within rehabilitation in an organized and theoretically-informed way.The insights from this study are important for the field of HIV and for advancing understanding of the complexities of stigma in the context of rehabilitation more broadly.This analysis offers guidance to rehabilitation providers about the nuanced and multi-faceted ways that stigma can occur in the context of rehabilitation, including within their own clinical practice.

Study protocol: becoming and being a mother living with HIV - a multicentre longitudinal mixed methods study among pregnant women living with HIV, non-pregnant women living with HIV and pregnant women not living with HIV in a high-income setting (the 2B MOM study)

INTRODUCTION

The success of combination antiretroviral therapy has decreased the risk of perinatal HIV transmission and normalised pregnancy in women living with HIV (WLWH). Despite these advances, WLWH still face complex medical and psychosocial issues during pregnancy and postpartum, and there is a gap of knowledge on the experiences of becoming and being a mother living with HIV in today's context. The overall aim of this study is to investigate psychosocial outcomes and experiences of WLWH in Scandinavia during pregnancy and early motherhood.

METHODS AND ANALYSIS

This is a multicentre longitudinal convergent mixed methods study consisting of a quantitative survey study, a qualitative interview study and a mixed methods analysis. The survey study aims to examine psychosocial outcomes of WLWH across the pregnancy - postpartum trajectory. Participants are pregnant WLWH living in Scandinavia. Two control groups of HIV-negative pregnant women and non-pregnant WLWH are also included. Data is collected in the third trimester, 3 and 6 months postpartum using standardised questionnaires. Statistical analysis will assess changes over time and identify predictors of adverse outcomes. The interview study seeks to understand experiences of pregnancy and becoming a mother while living with HIV. Pregnant WLWH who are enrolled in the survey study will be asked to participate in individual interviews in the third trimester and 6 months postpartum. Data will be analysed using narrative analysis. The survey and interview results will be merged in a mixed methods analysis to assess confirmation, expansion or discordance between the data sets.

ETHICS AND DISSEMINATION

Approval from the Danish Data Protection Agency (VD-2018-253), and the Finnish and Swedish Ethics Committees have been obtained (HUS/1330/2019 and Dnr: 2019-04451, respectively). Study results will be disseminated to patient organisations, through publications in peer-reviewed journals and at scientific conferences.

Reframing HIV Stigma and Fear : Considerations from Social-ecological and Evolutionary Theories of Reproduction

HIV stigma and fears surrounding the disease pose a challenge for public health interventions, particularly those that target pregnant women. In order to reduce stigma and improve the lives of vulnerable populations, researchers have recognized a need to integrate different types of support at various levels. To better inform HIV interventions, the current study draws on social-ecological and evolutionary theories of reproduction to predict stigma and fear of contracting HIV among pregnant women in South India. The aims of this study were twofold: compare the social-ecological model to a modified maternal-fetal protection model and test a combined model that included strong predictors from each model. The study took place in 2008-2011 in Mysore District, Karnataka, India. Using data from a cross-sectional survey and biological indicators of health, we statistically modeled social-ecological variables representing individual, interpersonal, and community/institutional levels. Participants were 645 pregnant women. The social-ecological and combined models were the best-fitting models for HIV-related stigma, and the combined model was the best fit for HIV-related fear. Our findings suggest that combining reproductive life history factors along with individual, interpersonal, and community/institutional factors are significant indicators of HIV-related stigma and fear. Results of this study support a multifaceted approach to intervention development for HIV-related stigma and fear. The combined model in this study can be used as a predictive model for future research focused on HIV stigma and fear, with the intent that dual consideration of social-ecological and evolutionary theories will improve public health communication efforts.

Chronic Hepatitis B stigma in Ghana: a qualitative study with patients and providers

OBJECTIVE

This study explored beliefs contributing to Hepatitis B stigma, and the ways in which Hepatitis B stigma manifests, from the perspectives of people with chronic Hepatitis B as well as healthcare providers in Northern and Southern Ghana.

DESIGN

We used an exploratory qualitative design with a purposive sampling technique. Face-to-face interviews and focus group discussions were conducted. Data were processed using QSR Nvivo V.10.0 and analysed using inductive thematic analysis.

SETTINGS

Participants were recruited from one tertiary and one regional hospital in Ghana between February and November 2017.

PARTICIPANTS

Overall, 18 people with chronic Hepatitis B (PWHB) and 47 healthcare providers (primary care physicians, nurses and midwives) between the ages of 21 and 57 years participated in the study.

RESULTS

PWHB face stigma in their sociocultural context and the healthcare environment. Three main beliefs underlying stigma were found: (1) the belief that Hepatitis B is highly contagious; (2) the belief that Hepatitis B is very severe and (3) the belief that Hepatitis B is caused by curses. Stigmatisation manifested as avoidance and social isolation (discrimination). In healthcare settings, stigmatisation manifested as excessive cautiousness, procedure postponement or avoidance, task-shifting and breaches of confidentiality.

CONCLUSIONS

Given the prevalence of incorrect knowledge, as reflected in the beliefs about Hepatitis B, we recommend public awareness campaigns that emphasise Hepatitis B transmission routes. Also, given the manifestations of the stigma in healthcare settings, we recommend the development and implementation of a continuing professional development programme on Hepatitis B and adjusted policy on Hepatitis B vaccination for Healthcare providers (HCPs).

Health-related quality of life of people living with HIV infection in Spain: a gender perspective

Studies exploring gender differences in health-related quality of life (HRQOL) of people living with HIV/AIDS (PLWHA) are scarce and contradictory. This study evaluated gender differences in HRQOL of 744 PLWHA with median (IQR) age 44 (37-48) years and HIV infection diagnosed 12 (5-20) years earlier. Results showed important differences between genders (p < .05). Better male physical health was related to being employed, not having economic worries, not receiving psychological support, not having injected drugs in past, low negative mood HIV-related, low HIV illness representation and internalized stigma, and high body image satisfaction and health behavior. For women, variables were fewer years since HIV diagnosis and low enacted stigma-personal experience of rejection. Mentally, variables in men were being employed, not having injected drugs, having a stable partner, high health behavior, use of problem-solving coping, personal autonomy and personal meaning. In women, better mental health was related to high CD4 cells, self-esteem and body image satisfaction, and negative mood HIV-related. Men and women coincided in absence of past opportunistic infections being related to better physical and mental health, and absence of side effects for physical health and low HIV-related stress and HIV illness representation for mental health. Our results highlight the need for detailed study of gender differences that identify the bio-psycho-socio inequalities that affect HRQOL.

Managing the need to tell: Triggers and strategic disclosure of thalassemia major in Singapore

This study explored patients' experiences and perceptions of living with thalassemia (an inherited hematologic disorder), perceptions of social stigma, and impact on disclosure decision-making. Semistructured, in-person interviews were conducted in Singapore with 30 individuals: 16 thalassemia major patients and 14 parents of children with thalassemia. Findings were indicative of felt or enacted stigma that may have influenced disclosure decisions. Although affected individuals commonly disclosed their thalassemia diagnosis to family members, they either downplayed the condition with or avoided disclosure to unrelated individuals. Disclosure outside the family occurred only in response to triggers, such as questions about absences due to medical care. Health professionals should provide anticipatory guidance about disclosure strategies when managing individuals with thalassemia.

Stigma as a barrier to family planning use among married youth in Ethiopia

Nearly 33 million female youths have an unmet need for voluntary family planning (FP), meaning they are sexually active and do not want to become pregnant. In Ethiopia, age at marriage remains low: 40% and 14% of young women aged 20-24 were married by the ages of 18 and 15, respectively. Despite increases in FP use by married 15- to 24-year-olds from 5% in 2000 to 37% in 2016, unmet need remains high at 19%. Supply-and-demand factors have been shown to limit FP use, yet little is known about how stigma influences FP use among youth. This study validates an anticipated stigma (expectation of discrimination from others) index and explores its effect on unmet need. A cross-sectional survey was implemented with 15- to 24-year-old female youth in Ethiopia in 2016. The analytic sample included married respondents with a demand (met and unmet need) for FP (n=371). A five-item anticipated stigma index (Cronbach's α=0.66) was developed using principal component factor analysis. These items related to fear, worry and embarrassment when accessing FP. The findings showed that 30% agreed with at least one anticipated stigma question; 44% had an unmet need; 58% were married before age 18; and 100% could name an FP method and knew where to obtain FP. In multivariate regression models, youth who experienced anticipated stigma were significantly more likely to have an unmet need, and those who lived close to a youth-friendly service (YFS) site were significantly less likely to have an unmet need. Interventions should address anticipated stigma while focusing on social norms that restrict married youth from accessing FP; unmet need may be mitigated in the presence of a YFS; and the anticipated stigma index appears valid and reliable but should be tested in other countries and among different adolescent groups.

Stigma and Spiritual Well-being among People Living with HIV/AIDS in Southern Appalachia

The Appalachian South is disproportionately affected by HIV/AIDS. Partly due to the negative connotation that this disease carries in religiously conservative areas, HIV-related stigma remains a critical barrier to HIV care in the South. However, spirituality is a well-documented, effective coping mechanism among persons living with HIV/AIDS (PLWH). The purpose of this study was to examine the relationship between HIV-related stigma and spiritual well-being among a sample of PLWH (n = 216) in Appalachian counties of Tennessee and Alabama using the HIV Stigma Scale and the Spiritual Well-being Scale. Overall, disclosure of HIV status was the most highly reported stigma concern. Women reported higher levels of stigma and religious well-being than men. While existential well-being was negatively correlated with stigma, no significant overall correlation was found between religious well-being and stigma. Our findings reveal the importance of defining theology and differentiating between cultural religious conditioning and internalized beliefs.

Being and Becoming a Helper: Illness Disclosure and Identity Transformations among Indigenous People Living With HIV or AIDS in Saskatoon, Saskatchewan

Saskatoon has nearly half of the diagnoses of HIV in Saskatchewan, Canada, with an incidence rate among Indigenous populations within inner-city contexts that is 3 times higher than national rates. Previous research does not adequately explore the relations between HIV vulnerabilities within these contexts and the experiences of illness disclosure that are informed by identity transformations, experiences of stigma, and social support. From an intersectionality framework and a constructivist grounded theory approach, this research involved in-depth, semistructured interviews with 21 Indigenous people living with HIV and/or AIDS in Saskatoon, both male and female. In this article, we present the key themes that emerged from the interviews relating to experiences of HIV disclosure, including experiences of and barriers to the disclosure process. In the end, we highlight the important identity transformation and role of being and becoming a "helper" in the community and how it can be seen as a potential support for effective community health interventions.

The role of enacted stigma in parental HIV disclosure among HIV-infected parents in China

Existing studies have delineated that HIV-infected parents face numerous challenges in disclosing their HIV infection to the children (“parental HIV disclosure”), and practices of parental HIV disclosure vary with individual characteristics, family contexts, and social environment. Using cross-sectional data from 1254 HIV-infected parents who had children aged 5–16 years in southwest China, the current study examined the association of parental HIV disclosure with mental health and medication adherence among parents and explored the possible effect of enacted stigma on such association. Multivariate analysis of variance revealed that parents who had experienced disclosure to children reported higher level enacted stigma, worse mental health conditions, and poorer medication adherence. Enacted stigma partially mediated the associations between disclosure and both mental health and medication adherence after controlling basic background characteristics. Our findings highlight the importance of providing appropriate disclosure-related training and counseling service among HIV-infected parents. In a social setting where HIV-related stigma is still persistent, disclosure intervention should address and reduce stigma and discrimination in the practice of parental HIV disclosure.

Decolonizing Scoping Review Methodologies for Literature With, for, and by Indigenous Peoples and the African Diaspora: Dialoguing With the Tensions

This article summarizes our deepened understanding of decolonizing research with, for, and by Indigenous peoples and peoples of African descent that emerged from conducting a scoping review of the methodological literature and reflecting on our review process. Although our review identified decolonizing methodologies as a promising approach, we questioned if our scoping review process engaged in decolonizing knowing. To unpack the epistemological tensions between decolonizing knowing and Western ways of doing scoping reviews, we engaged in individual and collective reflective processes- dialoguing with the tensions-moving from individual immersion in the literature to transformative dialogues among the team. In reflecting upon our tensions with the scoping review process, themes that emerged included (a) ontological/epistemological disjunctures, (b) tensions with concepts and language, and (c) relationships with the literature and beyond. This reflexive process provides valuable insight into ways in which review methods might be made a decolonizing research experience.

Intersectional stigma among midlife and older Black women living with HIV

HIV-related stigma is a barrier to the prevention and treatment of HIV. For midlife and older Black women, the nature and intensity of HIV-related stigma may be compounded by their multiple marginalised social status based on gender, race, and age. We examined the perceptions and experiences of HIV-related stigma among midlife and older Black women living in Prince George's County, Maryland, USA. Between 2014 and 2015, we conducted semi-structured interviews with a sample of 35 midlife and older Black women living with HIV. Using a modified grounded theory approach, we explored emergent themes related to the manifestation and experience of intersectional stigma and changes in stigma experience over time. Our findings suggest that intersectional stigma is a central feature in midlife and older Black women's lives, with women reporting experiences of intersectional stigma at the interpersonal/familial, community, and institutional/structural levels. Although women acknowledged gradual acceptance of their HIV-positive status over time, they continued to experience negative responses related to gender, race, age, and disease. Our findings indicate that a more robust understanding of the impact of HIV-related stigma requires work to consider the complex manifestations of intersectional stigma among an increasingly aging population of Black women in the USA.

Adolescent pre-exposure prophylaxis for HIV prevention: current perspectives

Adolescents are a critical population that is disproportionately impacted by the HIV epidemic. More than 2 million adolescents between the age group of 10 and 19 years are living with HIV, and millions are at risk of infection. HIV risks are considerably higher among girls, especially in high-prevalence settings such as eastern and southern Africa. In addition to girls, there are other vulnerable adolescent subgroups, such as teenagers, who use intravenous (IV) drugs, gay and bisexual boys, transgender youth, male sex workers, and people who fall into more than one of these categories. Pre-exposure prophylaxis (PrEP) is a new intervention for people at high risk for acquiring HIV, with an estimated HIV incidence of >3%. Recent data from trials show evidence of the efficacy of PrEP as a powerful HIV prevention tool in high-risk populations, including men who have sex with men, HIV-1-serodiscordant heterosexual couples, and IV drug users. The reported efficacy in those trials of the daily use of oral tenofovir, alone or in combination with emtricitabine, to prevent HIV infection ranged from 44% to 75% and was heavily dependent on adherence. Despite the proven efficacy of PrEP in adult trials, concerns remain about its feasibility in real-life scenarios due to stigma, cost, and limited clinician experience with PrEP delivery. Recent studies are attempting to expand the inquiry into the efficacy of such HIV prophylaxis approaches in adolescent populations, but there are still many gaps in knowledge, and no country has yet approved it for use with adolescents. The aim of this review was to identify and summarize the evidence from studies on PrEP for adolescents. We have compiled and reviewed published studies focusing on safety, feasibility, adherence to therapeutics, self-perception, and legal issues related to PrEP in people aged between 10 and 24 years.

Gender, HIV Testing and Stigma: The Association of HIV Testing Behaviors and Community-Level and Individual-Level Stigma in Rural South Africa Differ for Men and Women

Stigma remains a significant barrier to HIV testing in South Africa. Despite being a social construct, most HIV-stigma research focuses on individuals; further the intersection of gender, testing and stigma is yet to be fully explored. We examined the relationship between anticipated stigma at individual and community levels and recent testing using a population-based sample (n = 1126) in Mpumalanga, South Africa. We used multi-level regression to estimate the potential effect of reducing community-level stigma on testing uptake using the g-computation algorithm. Men tested less frequently (OR 0.22, 95% CI 0.14-0.33) and reported more anticipated stigma (OR 5.1, 95% CI 2.6-10.1) than women. For men only, testing was higher among those reporting no stigma versus some (OR 1.40, 95% CI 0.97-2.03; p = 0.07). For women only, each percentage point reduction in community-level stigma, the likelihood of testing increased by 3% (p < 0.01). Programming should consider stigma reduction in the context of social norms and gender to tailor activities appropriately.

Factors associated with low neighborhood cohesion among women living with HIV impacted by social-structural inequities in British Columbia

Built and social environments, including one's perception of their environment, are important determinants of health. The intersection of gender and HIV status may complicate the role of neighborhood cohesion in safety, personal well-being, and health outcomes for populations impacted by social and structural inequities. Among women in particular, social cohesion within the neighborhood they reside in may have a greater influence on health outcomes compared to their male counterparts. We sought to examine perception of neighborhood cohesion (validated scale with a range 0-100, with higher scores indicating higher perceived neighborhood cohesion) among women living with HIV, impacted by social-structural inequities, receiving combination antiretroviral therapy, and enrolled in the Longitudinal Investigations into Supportive Ancillary health services (LISA) study in British Columbia, Canada. Cross-sectional data on neighborhood cohesion and socio-demographic data were collected in an interviewer-administered survey. Of the 1,000 LISA participants interviewed, 908 (including 249 women and 659 men) had complete data for the variables of interest. At the bivariate level, women had worse perceived neighborhood cohesion scores compared to men (median: 56 [95% CI: 44-66] vs. 60 [95% CI: 47-71]). Multivariable model results indicated that for women living with HIV in our sample, greater neighborhood cohesion scores were positively associated with stable housing (β coefficient = 7.85; 95% CI: 3.61, 12.10, p < 0.001), and negatively associated with greater perceived HIV stigma (β coefficient = -1.19; 95% CI: -2.24 to-0.15; p = 0.025). The results illustrate the gendered nature of experiencing built and social environments, and highlight the need for women-centred interventions to address the social determinants of HIV burden associated with negative perceptions of neighborhood cohesion.

Changes in Psychosocial Measures After a 6-Week Field Trial

PURPOSE

The purpose of this study was to assess the extent to which intervention with hearing aids, namely, a 6-week hearing aid field trial, can minimize the psychosocial consequences of hearing loss in adults who have previously not sought treatment for their hearing loss.

METHOD

Twenty-four adults with mild to moderate bilateral sensorineural hearing loss, who had never worn hearing aids or sought help for their hearing loss, participated in this study. Participants were fitted with receiver-in-canal hearing aids, bilaterally, and wore them for 6 weeks. Participants completed subjective measures of hearing handicap and attitudes about hearing loss and hearing aids before, during, and after the hearing aid trial. A control group of age-matched participants followed the same experimental protocol, except they were not fitted with hearing aids.

RESULTS

Using hearing aids for 6 weeks significantly reduced participants' perceived stigma of hearing aids, personal distress and inadequacy due to hearing difficulties, and hearing handicap.

CONCLUSIONS

A hearing aid trial can have a positive effect on a person's attitudes toward wearing hearing aids and decrease hearing handicap.

What is the relationship between increased access to HAART, relationship status and fertility decisions amongst HIV-positive women? A literature review and meta-analysis

AIMS AND OBJECTIVES

To investigate the relationship between fertility decisions, to have already had a child or to desire to have one in the future, and the prognostic factors; access to antiretrovirals, the time since these became widely available (year of the study); and relationship status.

BACKGROUND

There have been significant advances in the treatment of human immunodeficiency virus with the advent of antiretroviral therapy which has been used to successfully reduce the rate of mother to child transmission; leading researchers to hypothesise that human immunodeficiency virus-positive women may desire to have children more so now than in the past. However, this topic is often not discussed in healthcare consultations.

DESIGN & METHODS

A systematic search was conducted on Cumulative Index of Nursing and Allied Health Literature and Medline, using the key terms 'fertility decisions' and 'human immunodeficiency virus positive'. A meta-analysis of proportions and a meta-regression were conducted using a random-effects model and a logit transformation to normalise the data. Heterogeneity was assessed using Q, I² and R² values, and p-values were produced for each regressed variable.

RESULTS

There was no statistically significant relationship between a desire to have children in the future and any of the prognostic variables. However, there were statistically significant relationships between already having had at least one child; being on antiretroviral therapy; wanting a child in the future; and being in a cohabiting partnership or marriage.

CONCLUSION

There are no reliable prognostic variables which can be used to predict fertility intentions in human immunodeficiency virus-positive women. There is, however, a significant proportion of women who wish to have children or who have already had children and are in need of reproductive counselling from their healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

A greater knowledge of factors which may influence reproductive decisions amongst human immunodeficiency virus-positive position will allow healthcare professionals to individualise the care they provide.

Understanding HIV-Related Stigma Among Women in the Southern United States: A Literature Review

Societal stigmatization of HIV/AIDS due to assumptions about transmission and associated behaviors plays a substantial role in the psychosocial well-being of people living with this chronic illness, particularly for women in traditionally conservative geographic regions. Known for social conservatism, the Southern United States (US) holds the highest incidence rate of HIV infection in the US. A systematic search of four databases was used to identify 27 relevant scientific articles pertaining to HIV-related stigma among women living with HIV/AIDS in the Southern US. These studies revealed a rudimentary understanding of stigma sources, effects, and stigma-reduction interventions in this population. Due to the cultural specificity of stigma, further differentiation of stigma in discrete sectors of the South as well as a dialogue about the moral implications of stigma is necessary to lay the groundwork for patient-centered interventions to mitigate the destructive effects of stigma experienced by women in this region.

A Structural Equation Model of HIV-Related Stigma, Racial Discrimination, Housing Insecurity and Wellbeing among African and Caribbean Black Women Living with HIV in Ontario, Canada

African and Caribbean Black women in Canada have new HIV infection rates 7 times higher than their white counterparts. This overrepresentation is situated in structural contexts of inequities that result in social, economic and health disparities among African and Caribbean Black populations. Economic insecurity is a distal driver of HIV vulnerability, reducing access to HIV testing, prevention and care. Less is known about how economic insecurity indicators, such as housing security, continue to influence the lives of women living with HIV following HIV-positive diagnoses. The aim of this study was to test a conceptual model of the pathways linking HIV-related stigma, racial discrimination, housing insecurity, and wellbeing (depression, social support, self-rated health). We implemented a cross-sectional survey with African and Caribbean Black women living with HIV in 5 Ontario cities, and included 157 participants with complete data in the analyses. We conducted structural equation modeling using maximum likelihood estimation to evaluate the hypothesized conceptual model. One-fifth (22.5%; n = 39) of participants reported housing insecurity. As hypothesized, racial discrimination had significant direct effects on: HIV-related stigma, depression and social support, and an indirect effect on self-rated health via HIV-related stigma. HIV-related stigma and housing insecurity had direct effects on depression and social support, and HIV-related stigma had a direct effect on self-rated health. The model fit the data well: χ² (45, n = 154) = 54.28, p = 0.387; CFI = 0.997; TLI = 0.996; RMSEA = 0.016. Findings highlight the need to address housing insecurity and intersecting forms of stigma and discrimination among African and Caribbean Black women living with HIV. Understanding the complex relationships between housing insecurity, HIV-related stigma, racial discrimination, and wellbeing can inform multi-level interventions to reduce stigma and enhance health.