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Shrestha A, Poudel L, Shrestha S, Jha N, Kuikel BS, Shakya P, Kunwar RS, Pandey LR, Kc MB, Wilson EC, Deuba K. Multilevel determinants of antiretroviral therapy initiation and retention in the test-and-treat era of Nepal: a qualitative study. BMC Health Serv Res 2024; 24:927. [PMID: 39138448 PMCID: PMC11323673 DOI: 10.1186/s12913-024-11311-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 07/12/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND The transition to the "test-and-treat" policy in Nepal in 2017, coupled with the rapid initiation of antiretroviral therapy (ART) in 2020, necessitates an in-depth understanding of factors influencing ART initiation and retention. This study investigates these factors from the perspectives of healthcare providers, families/communities, and people living with HIV (PLHIV). METHODS Employing a qualitative design, in-depth interviews were conducted with 24 ART clients and 26 healthcare providers across different provinces of Nepal. A comprehensive interview guide facilitated the exploration of experiences and perceptions. Interviews were transcribed verbatim, and thematic analysis was applied to distill key insights. Guided by a socio-ecological model, interviews were analyzed to identify the barriers and facilitators to ART initiation and continuation at the individual, family/community, and health system levels. RESULTS Facilitators and barriers were identified at three levels. Individual-level facilitators included fear of death, perceived health benefits, knowledge about HIV/ART, confidentiality, and financial support. Barriers encompassed concerns about lifelong medication, side effects, denial of HIV status, fear of disclosure, and financial constraints. At the family/community level, support from family and community health workers facilitated ART adherence, while social stigma and discrimination posed barriers. The health system's role was dual; the provision of free treatment, a client tracking system and a robust drug supply chain were facilitators, whereas logistical challenges and service accessibility during the COVID-19 pandemic were notable barriers. CONCLUSIONS This study highlights the various factors that influence ART initiation and retention in Nepal during the test-and-treat era. Tailored interventions should focus on increasing awareness about HIV and ART, strengthening healthcare systems, ensuring availability of medications, and providing accessible treatment during service disruptions. Furthermore, these interventions should encourage supportive environments at the individual, community, and healthcare system levels. Taking this holistic approach is essential for effectively implementing ART and achieving long-term health outcomes in light of changing public health policies.
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Affiliation(s)
- Archana Shrestha
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA
- Institute for Implementation Science and Health, Kathmandu, Nepal
| | - Lisasha Poudel
- Institute for Implementation Science and Health, Kathmandu, Nepal
| | - Soniya Shrestha
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Niharika Jha
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Bihari Sharan Kuikel
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | | | | | - Lok Raj Pandey
- National Centre for AIDS & STD Control, Ministry of Health and Population, Kathmandu, Nepal
| | - Man Bahadur Kc
- National Centre for AIDS & STD Control, Ministry of Health and Population, Kathmandu, Nepal
| | - Erin C Wilson
- San Francisco Department of Public Health, San Francisco, CA, USA
| | - Keshab Deuba
- Public Health and Environment Research Centre (PERC), Lalitpur, Nepal.
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
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Campbell LS, Knight L, Masquillier C, Wouters E. Including the Household: Individual, Community and Household Factors Affecting Antiretroviral Therapy Adherence After ART Initiation in Cape Town, South Africa. AIDS Behav 2024:10.1007/s10461-024-04447-3. [PMID: 39090458 DOI: 10.1007/s10461-024-04447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2024] [Indexed: 08/04/2024]
Abstract
Antiretroviral therapy (ART) adherence is crucial for health outcomes of people living with HIV (PLHIV), influenced by a complex interplay of individual, community, and household factors. This article focuses on the influence of household factors, as well as individual and community factors, on ART adherence among PLHIV in Cape Town who have recently initiated ART. Baseline data for a cluster-randomized controlled trial were collected from 316 PLHIV in 12 districts in Cape Town between 6th May 2021 and 22nd May 2022. Zero-inflated Poisson models, with cluster-adjusted standard errors, were used to analyse the association between individual, household, and community factors and ART adherence measures. At the household-level, household support was associated with both better self-rated adherence (exp(β) = 0.81, z = - 4.68, p < 0.001) and fewer days when pills were missed (exp(β) = 0.65, z = - 2.92, p = 0.003). Psychological violence (exp(β) = 1.37, z = 1.97, p = 0.05) and higher household asset scores (exp(β) = 1.29, z = - 2.83, p = 0.05) were weakly associated with poorer ART adherence. At the individual-level, male gender (exp(β) = 1.37, z = 3.95, p < 0.001) and reinitiating ART (exp(β) = 1.35, z = 3.64, p < 0.001) were associated with worse self-rated ART adherence; higher education levels (exp(β) = 0.30 times, z = - 3.75, p < 0.001) and better HIV knowledge (exp(β) = 0.28, z = - 2.83, p = 0.005) were associated with fewer days where pills were missed. At the community-level, community stigma was associated with worse self-rated ART adherence (exp(β) = 1.24, z = 3.01, p = 0.003). When designing interventions to improve ART adherence, household, individual and community factors should all be considered, particularly in addressing gender-based disparities, reducing stigma, tackling violence, and enhancing household support.Clinical Trial Number: Pan African Clinical Trial Registry, PACTR201906476052236. Registered on 24 June 2019.
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Affiliation(s)
- Linda S Campbell
- Faculty of Social Sciences, Centre for Population, Family and Health, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium.
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium.
| | - Lucia Knight
- Division of Social and Behavioural Sciences, Faculty of Health Sciences, School of Public Health, University of Cape Town, Cape Town, South Africa
- School of Public Health, Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Caroline Masquillier
- Faculty of Social Sciences, Centre for Population, Family and Health, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Family Medicine and Population Health, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Edwin Wouters
- Faculty of Social Sciences, Centre for Population, Family and Health, University of Antwerp, Prinsstraat 13, 2000, Antwerp, Belgium
- Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa
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Mirti AF, Kane JC, Watt KG, Desmond C, Gruver RS, Munsami A, Myeza NP, Norwitz GA, Davidson LL. Does perceived caregiver HIV stigma and depression increase adolescent neuro-behavioral difficulties? A mediation analysis in the Asenze Cohort. RESEARCH SQUARE 2024:rs.3.rs-4543382. [PMID: 39070660 PMCID: PMC11276019 DOI: 10.21203/rs.3.rs-4543382/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
People living with HIV (PLWH) often experience HIV related stigma that is, in turn, associated with several negative health outcomes including depression, harmful drinking, and intimate partner violence. Despite knowledge of these proximal impacts of HIV stigma on PLWH, less is known about the impact that Caregivers living with HIV's perception of stigma has on the health and behavior of adolescents in their care. Utilizing data from adolescents and their primary caregivers from the population-based Asenze cohort study in KwaZulu-Natal, South Africa, we conducted a path analysis to determine if caregiver depression [operationalized as mental health functioning] is a mediator of the hypothesized association between caregiver HIV stigma and adolescent neurodevelopmental behavior including internalizing and externalizing behaviors. Results suggest good model fit and a statistically significant relationship between caregiver HIV stigma and caregiver mental health functioning. However, neither the direct nor indirect (including potential mediator caregiver mental health functioning) effect of HIV stigma on adolescent behavioral difficulties was statistically significant. This paper builds on previous research demonstrating the relationship between HIV stigma and depression, highlighting the need for continued study of underlying mechanisms that impact the stigma and health of PLWH and others important to them such as their children.
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Affiliation(s)
- Amaleah F. Mirti
- Department of Sociomedical Sciences, Columbia University, New York City, USA
| | - Jeremy C. Kane
- Department of Epidemiology, Columbia University, New York City, USA
| | - Kathryn G. Watt
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Chris Desmond
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
- School of Economics and Finance, University of the Witwatersrand, Johannesburg, South Africa
| | - Rachel S. Gruver
- Department of Epidemiology, Columbia University, New York City, USA
| | - Adele Munsami
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Nonhlanhla P. Myeza
- Centre for Rural Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa
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Filiatreau LM, Ebasone PV, Dzudie A, Wainberg M, Yotebieng M, Anastos K, Parcesepe AM. Intersectional HIV- and Depression-Related Stigma Among People with HIV Entering HIV Care in Cameroon. AIDS Behav 2024:10.1007/s10461-024-04375-2. [PMID: 38767726 DOI: 10.1007/s10461-024-04375-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
Mental health-related stigma is a prominent barrier to improved mental health outcomes globally and may be particularly harmful to populations with other stigmatized identities. We aimed to understand intersectional depression- and HIV-related stigma among people with HIV (PWH) entering HIV care in Cameroon. Using baseline data from a cohort of PWH entering HIV care in Cameroon between 2019 and 2020, we characterized depression- and HIV-related stigma in the population overall and by sociodemographic sub-group. We also explored substantively meaningful variation in stigma endorsement by depressive symptom severity (Patient Health Questionnaire-9 [PHQ-9]) and causal attribution of depression. Among those with elevated depressive symptoms (PHQ-9 scores > 4), we estimated the association between stigma type and depressive symptom severity using binomial regression. Among 398 participants, 49% endorsed low HIV- and depression-related stigma (N = 195), 10% endorsed high HIV- and depression-related stigma (N = 38), 29% endorsed high depression-related stigma only (N = 116), and 12% endorsed high HIV-related stigma only (N = 49). Respondents with and without heightened depressive symptoms commonly believed depressive symptoms were caused by HIV (N = 140; 32.9%). Among those with elevated depressive symptoms, the prevalence of moderate to severe symptoms was higher among those endorsing high HIV-related stigma only (prevalence ratio 1.55; 95% confidence interval: 1.01, 2.37) compared to those reporting low HIV- and depression-related stigma. HIV- and depression-related stigma are both common among PWH entering HIV care in Cameroon. The consistent association between HIV-related stigma and poor psychosocial well-being among people with HIV necessitates the urgent scale-up of evidence-based HIV-related stigma interventions specifically.
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Affiliation(s)
- Lindsey M Filiatreau
- School of Medicine, Division of Infectious Diseases, Washington University in St. Louis, St. Louis, MO, USA.
| | | | - Anastase Dzudie
- Clinical Research Education Networking and Consultancy, Yaoundé, Cameroon
| | - Milton Wainberg
- Department of Psychiatry, Columbia University and New York State Psychiatric Institute, New York, NY, USA
| | - Marcel Yotebieng
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kathryn Anastos
- Departments of Medicine and Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Angela M Parcesepe
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Kabiibi F, Tamukong R, Muyindike W, Yadesa TM. Virological Non-Suppression, Non-Adherence and the Associated Factors Among People Living with HIV on Dolutegravir-Based Regimens: A Retrospective Cohort Study. HIV AIDS (Auckl) 2024; 16:95-107. [PMID: 38533311 PMCID: PMC10964029 DOI: 10.2147/hiv.s449947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 03/13/2024] [Indexed: 03/28/2024] Open
Abstract
Background HIV is one of the leading causes of morbidity and mortality, with 39.0 million people living with HIV worldwide, 25.6 million of whom reside in the African region. Highly active anti-retroviral therapy (HAART) has improved survival and quality of life, yet some patients develop viral non-suppression. Dolutegravir (DTG) has been recommended since 2018 as a first-line treatment option in low- and middle-income countries owing to its effectiveness, low cost, and tolerability, but some studies have reported virological non-suppression with its use. This study aims to explore the prevalence and factors associated with virological non-suppression in adults taking DTG-based regimens in Mbarara Regional Referral Hospital. Methods A retrospective cohort study was carried out among people living with HIV (PLWHIV) taking DTG-based HAART regimens by way of record review. SPSS was used for analysis, and both binary and multivariate logistic regression analyses were performed to test associated factors. Results Among the 422 participants' records reviewed, 62.8% were female (median age 40 years, IQR=13). The prevalence of virological non-suppression was 4.2%. Poor adherence to HAART was significantly associated with virological non-suppression, with 100.3 increased adjusted odds (95% CI: 28.90-348.12, p<0.001) compared to those with a record of good adherence. The reasons for poor adherence included alcohol use, stigma, forgetting to take medication, transport problems, and irregular timing of swallowing. Conclusion This study found poor adherence to be associated with a 4.2% prevalence of virological non-suppression among PLWHIV in a large public HIV care clinic. Despite the high suppression rates on DTG-based regimens, adherence counseling and viral load monitoring need to be emphasized at all HIV care centers to mark the trends of virological non-suppression.
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Affiliation(s)
- Florence Kabiibi
- Department of Pharmacy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Robert Tamukong
- Department of Pharmacy, Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Tadele Mekuriya Yadesa
- Department of Pharmacy, Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Clinical Pharmacy and Pharmacy Practice, Kampala International University, Ishaka-Bushenyi, Uganda
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Saidi F, Phanga T, Graybill LA, Mollan KR, Hill LM, Sibande W, Msowoya G, Thom A, Rosenberg NE, Freeborn K, Amico KR, Phiri S, Mutale W, Chi BH. Acceptability of a Combination Adherence Strategy to Support HIV Antiretroviral Therapy and Pre-exposure Prophylaxis Adherence During Pregnancy and Breastfeeding in Malawi. AIDS Behav 2023; 27:4022-4032. [PMID: 37392270 DOI: 10.1007/s10461-023-04116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/18/2023] [Indexed: 07/03/2023]
Abstract
In two parallel pilot studies, we implemented a combination adherence intervention of patient-centered counselling and adherence supporter training, tailored to support HIV treatment (i.e., antiretroviral therapy) or prevention (i.e., pre-exposure prophylaxis, or PrEP) during pregnancy and breastfeeding. Using a mixed-methods approach, we evaluated the intervention's acceptability. We investigated engagement, satisfaction, and discussion content via survey to all 151 participants assigned to the intervention arm (51 women living with HIV, 100 PrEP-eligible women without HIV). We also conducted serial in-depth interviews with a subgroup (n = 40) at enrollment, three months, and six months. In the quantitative analysis, the vast majority reported high satisfaction with intervention components and expressed desire to receive it in the future, if made available. These findings were supported in the qualitative analysis, with favorable comments about counselor engagement, intervention content and types of support received from adherence supporters. Overall, these results demonstrate high acceptability and provide support for HIV status-neutral interventions for antiretroviral adherence.
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Affiliation(s)
- Friday Saidi
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi.
- Department of Obstetrics and Gynecology, Kamuzu University of Health Sciences, Lilongwe, Malawi.
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Twambilile Phanga
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Lauren A Graybill
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Katie R Mollan
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Lauren M Hill
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Watson Sibande
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Getrude Msowoya
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Annie Thom
- University of North Carolina (UNC) Project Malawi, Bag A-104, Lilongwe, Malawi
| | - Nora E Rosenberg
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kellie Freeborn
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - K Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Wilbroad Mutale
- Department of Health Policy, University of Zambia School of Public Health, Lusaka, Zambia
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Davtyan M, Kacanek D, Lee J, Berman C, Chadwick EG, Smith R, Salomon L, Frederick T. The role of internalised HIV stigma in disclosure of maternal HIV serostatus to children perinatally HIV-exposed but uninfected: a prospective study in the United States. J Int AIDS Soc 2023; 26 Suppl 4:e26167. [PMID: 37909234 PMCID: PMC10618870 DOI: 10.1002/jia2.26167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 08/23/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION Decisions to disclose HIV serostatus may be complicated by internalised HIV stigma. We evaluated the association of internalised HIV stigma in biological mothers living with HIV with disclosure of their serostatus to their children perinatally HIV-exposed but uninfected (CHEU). METHODS Mothers and their CHEU were enrolled in the United States (U.S.)-based Surveillance Monitoring for Antiretroviral Therapy (ART) Toxicities (SMARTT) study of the Pediatric HIV/AIDS Cohort Study (PHACS), a longitudinal study of outcomes related to in utero exposure to HIV and ART among CHEU. Mothers completing at least one stigma and disclosure assessment starting at the child's age 11-, 13-, 15- and/or 17-year study visits between 16 August 2016 and 1 October 2020 were eligible. Stigma was measured with the 28-item Internalised HIV Stigma Scale (IHSS). Mean stigma scores were linearly transformed to a range of 0-100, with higher scores indicating greater levels of stigma. At each visit, mothers were asked if their child was aware of their HIV diagnosis and at what age the child became aware. The Kaplan-Meier estimator evaluated the cumulative probability of disclosure at each child age. Logistic regression models with generalised estimating equations to account for repeated measures were fit to examine the association between stigma and disclosure, controlling for relevant socio-demographic variables. RESULTS Included were 438 mothers of 576 children (mean age 41.5 years, 60% U.S.-born, 60% Black/African American and 37% with household income ≤$10,000). The prevalence of disclosure across all visits was 29%. Mothers whose children were aware versus not aware of their serostatus reported lower mean IHSS scores (38.2 vs. 45.6, respectively). The cumulative proportion of disclosure by age 11 was 18.4% (95% CI: 15.5%, 21.8%) and 41% by age 17 (95% CI: 35.2%, 47.4%). At all child ages, disclosure was higher among children of U.S.-born versus non-U.S.-born mothers. After adjusting for age, marital status and years since HIV diagnosis, higher IHSS scores were associated with lower odds of disclosure (OR = 0.985, 95% CI: 0.975, 0.995). CONCLUSIONS Providing support to women as they make decisions about serostatus disclosure to their children may entail addressing internalised HIV stigma and consideration of community-level factors, particularly for non-U.S.-born mothers.
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Affiliation(s)
- Mariam Davtyan
- Department of PediatricsKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Deborah Kacanek
- Harvard T.H. Chan School of Public HealthCenter for Biostatistics in AIDS ResearchBostonMassachusettsUSA
| | - Jessica Lee
- Harvard T.H. Chan School of Public HealthCenter for Biostatistics in AIDS ResearchBostonMassachusettsUSA
| | - Claire Berman
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Ellen G. Chadwick
- Department of PediatricsFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | - Renee Smith
- Department of PediatricsCollege of MedicineUniversity of IllinoisChicagoIllinoisUSA
| | - Liz Salomon
- Department of EpidemiologyHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Toinette Frederick
- Department of PediatricsKeck School of MedicineUniversity of Southern CaliforniaLos AngelesCaliforniaUSA
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Gutin SA, Ruark A, Darbes LA, Neilands TB, Mkandawire J, Conroy AA. Supportive couple relationships buffer against the harms of HIV stigma on HIV treatment adherence. BMC Public Health 2023; 23:1878. [PMID: 37770885 PMCID: PMC10540419 DOI: 10.1186/s12889-023-16762-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/14/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION HIV stigma can impact couple relationships through stress or bring partners closer through shared experiences. Conversely, couple relationships may protect against the harms of stigma, including anticipated stigma on negative health outcomes. Yet few studies have assessed the potential link between HIV stigma, relationship dynamics, and antiretroviral therapy (ART) adherence. Using dyadic data from a cross-sectional study of Malawian couples living with HIV, we tested associations between anticipated stigma and: 1) relationship dynamics (e.g., trust, sexual satisfaction, communication) and partner support; and 2) self-reported ART adherence. METHODS Heterosexual couples (211 couples, 422 individuals) with at least one partner on ART were recruited from clinics in Zomba, Malawi. Partners completed separate surveys on anticipated stigma, relationship dynamics, and ART adherence. Linear mixed models evaluated associations between anticipated stigma and relationship dynamics, and whether associations varied by gender. Generalized estimating equation models tested for associations between anticipated stigma and high ART adherence (90-100% vs. < 90%) at the individual level, and whether they were moderated by relationship dynamics at the couple level. RESULTS Couples' relationship length averaged 12.5 years, 66.8% were HIV sero-concordant, and 95.6% reported high ART adherence. In multivariable models, sexual satisfaction (β = -0.22, 95%CI = -0.41;-0.03, p = 0.020) and partner social support (β = -0.02, 95%CI = -0.04;-0.01, p < 0.01) were negatively associated with anticipated stigma. Significant interaction effects showed that adherence is moderated in couples with higher partner support and sexual satisfaction such that adherence is lowest when anticipated stigma is high and social support is low, and that adherence is lowest when anticipated stigma is high and sexual satisfaction is low. CONCLUSIONS Increased anticipated stigma is most associated with lower ART non-adherence at lower levels of social support and sexual satisfaction. Conversely, supportive and fulfilling relationships may buffer the negative association between stigma and ART adherence. Couples' interventions that focus on improving communication and support systems within couples could reduce the negative impacts of anticipated stigma on couples living with HIV.
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Affiliation(s)
- Sarah A Gutin
- Department Of Community Health Systems, School of Nursing, University of California, San Francisco (UCSF), 2 Koret Way, San Francisco, CA, 94143, USA.
| | - Allison Ruark
- Wheaton College, 501 College Avenue, Wheaton, IL, USA
| | - Lynae A Darbes
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 North Ingalls Building, Ann Arbor, MI, USA
| | - Torsten B Neilands
- Division of Prevention Sciences, University of California, San Francisco (UCSF), 550 16Th. Street, #3311, San Francisco, CA, 94158, USA
| | - James Mkandawire
- Invest in Knowledge, Old Naisi Road, P.O. Box 506, Zomba, Malawi
| | - Amy A Conroy
- Division of Prevention Sciences, University of California, San Francisco (UCSF), 550 16Th. Street, #3311, San Francisco, CA, 94158, USA
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Gouider R, Lorenz DH, Craven A, Grisold W, Dodick DW. Advocacy for patients with headache disorders. eNeurologicalSci 2023; 31:100466. [PMID: 37250108 PMCID: PMC10209324 DOI: 10.1016/j.ensci.2023.100466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 04/07/2023] [Accepted: 05/09/2023] [Indexed: 05/31/2023] Open
Abstract
Primary headache disorders are worldwide highly prevalent and burdensome and should be therefore considered as a global public health priority. However, too many patients with primary headache disorders still do not receive satisfying care. The most likely identified reasons for such a scenario - lack of public awareness, stigma, lack of trained professionals with inadequate healthcare systems and policies - are remediable. Despite the progresses that were made in headache advocacy, these efforts have not yielded substantial improvements in research funding or access to specialty care and even standards of care. The situation is more complex in Low and Middle Income Countries (LMICs) where headache advocacy is urgently needed given the magnitude of the difficulties that patients with primary headache disorders face in accessing care. The growing emergence of coordinated, collaborative, patient-centered advocacy efforts with improved patient-clinician partnership is an opportunity to enhance progress in advocacy for a satisfying life and optimal and equitable care for people with primary headache disorders. LMICs can benefit greatly from coordinating these efforts on a global scale. The recent organization of a training program on headache diagnosis and management for healthcare professionals in Africa is a concrete example.
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Affiliation(s)
- Riadh Gouider
- Neurology Department, LR18SP03, Razi Universitary Hospital, 1 rue des orangers Manouba, 2010 Tunis, Tunisia
- Faculty of Medicine of Tunis, University of Tunis El Manar, 15, Rue Djebel Akhdhar, La Rabta, 1007, Tunis, Tunisia
- Clinical Investigation Center (CIC) "Neurosciences and Mental Health", Razi Universitary Hospital, 1 rue des orangers Manouba, 2010 Tunis, Tunisia
| | | | - Audrey Craven
- European Federation of Neurological Associations & European Headache & Migraine Alliance, Dublin, Ireland
| | - Wolfgang Grisold
- Ludwig Boltzmann Institute for Experimental und Clinical Traumatology, Donaueschingenstraße 13, A-1200, Vienna, Austria
| | - David W. Dodick
- Mayo Clinic Arizona, Chief Science Officer, Atria Academy of Science and Medicine, USA
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Macleod D, Shanaube K, Skalland T, Limbada M, Mandla N, Bwalya J, Schaap A, Yang B, Donnell D, Piwowar-Manning E, Eshleman SH, Hoddinott G, Bond V, Moore A, Griffith S, Bock P, Ayles H, Fidler S, Hayes R, Floyd S. Viral suppression and self-reported ART adherence after 3 years of universal testing and treatment in the HPTN 071 (PopART) community-randomised trial in Zambia and South Africa: a cross-sectional analysis. Lancet HIV 2022; 9:e751-e759. [PMID: 36332652 PMCID: PMC9646982 DOI: 10.1016/s2352-3018(22)00237-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 07/25/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND In 2014, UNAIDS set the target that 90% of individuals on antiretroviral therapy (ART) be virally suppressed. Here, we use data from the HPTN 071 (PopART) trial to report whether the introduction of universal testing and treatment has affected viral suppression or treatment adherence among individuals who self-reported they were taking ART, and identify risk factors for these outcomes. METHODS This was a cross-sectional study nested within the randomly selected population cohort of the PopART trial. The trial took place in 21 communities in Zambia and South Africa. Analyses included 3570 HIV-positive participants who were seen at the second follow-up visit in 2016-17 and who self-reported that they were currently taking ART. Viral suppression was defined as HIV RNA of less than 400 copies per mL from a blood sample collected during the cohort visit, and ART adherence was measured using self-reporting (reported as no missed pills in last 7 days). Prevalences of these outcomes were compared across three trial arms using a two-stage approach suitable for clustered data. Each arm consisted of seven communities, with one arm receiving a combination HIV prevention package including immediate ART initiation, one receiving a combination HIV prevention package excluding immediate ART initiation and one arm receving standard of care. Risk factors for each of the outcomes were assessed using logistic regression. FINDINGS Among the 3570 participants who self-reported that they were currently on ART, 416 (11·7%) of 3554 were not virally suppressed (16 were missing viral suppression status) and 345 (9·7%) of 3566 reported being non-adherent to ART (four were missing adherence status). The proportion not virally suppressed was higher in communities in South Africa (195 [16·4%] of 1191) than in Zambia (221 [9·4%] of 2363). There was no evidence that the prevalence of the outcomes differed between trial arms. There was evidence that men, younger individuals, individuals who reported participating in harmful alcohol use, and those who reported internalised stigma were more likely to be non-adherent, and not virally suppressed. INTERPRETATION The results assuaged concerns that early ART initiation in a universal testing and treatment setting could lead to reduced adherence and viral suppression. FUNDING US National Institute of Allergy and Infectious Diseases (which is a part of the National Institutes of Health), the International Initiative for Impact Evaluation with support from the Bill & Melinda Gates Foundation, US President's Emergency Plan for AIDS Relief, and Medical Research Council UK.
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Affiliation(s)
- David Macleod
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Kwame Shanaube
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | | | - Mohammed Limbada
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Nomtha Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Justin Bwalya
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ab Schaap
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Blia Yang
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Deborah Donnell
- HPTN Statistical and Data Management Centre, Seattle, WA, USA
| | | | - Susan H Eshleman
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Virginia Bond
- Global Health and Development Department, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK; Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Ayana Moore
- FHI 360, HIV Prevention Trials Network, Durham, NC, USA
| | - Sam Griffith
- FHI 360, HIV Prevention Trials Network, Durham, NC, USA
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Helen Ayles
- Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Sarah Fidler
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Richard Hayes
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Sian Floyd
- International Statistics and Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Hossain F, Hasan M, Begum N, Mohan D, Verghis S, Jahan NK. Exploring the barriers to the antiretroviral therapy adherence among people living with HIV in Bangladesh: A qualitative approach. PLoS One 2022; 17:e0276575. [PMID: 36269716 PMCID: PMC9586390 DOI: 10.1371/journal.pone.0276575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 10/10/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Since the evolution of highly active antiretroviral therapy (ART), a near-perfect ART adherence level (>95%) is needed to control viral suppression. Non-adherence to treatment may lead to acquired immunodeficiency syndrome (AIDS) and drug resistance. Though the Bangladesh government provides free treatment and counselling services to people living with human immunodeficiency virus (PLHIV), only 22% of the identified PLHIV continue treatment. Therefore, this study aims to explore the barriers that obstruct the Bangladeshi PLHIV to ensure ART adherence. METHODS We conducted a qualitative study in Dhaka, Bangladesh, and recruited the sensitive study population following non-probability, mainly purposive sampling from a community-based registered organization for PLHIV. We conducted the in-depth interview using a semi-structured guideline with 15 consented respondents. We transcribed the audio-recorded interviews in the local language (Bangla) and then translated those into English for data analysis. During the data extraction process, the lead and corresponding authors independently extracted raw data to generate different themes and sub-themes and invited other authors to contribute when they could not solve any discrepancies. RESULTS The study identified three significant categories of barriers at the individual, community, and institutional levels that negatively interfered with ART adherence. The most dominant barriers were discrimination and rejection related to stigma, as almost all participants mentioned these barriers. Stigmatizing attitudes and the discriminatory act of the community people and healthcare providers critically affected their treatment adherence. Other leading barriers were improper inventory management of ART-related medicines and CD4 tests and lack of proper counselling. In addition, we found that a positive approach toward life and family support motivated some respondents to overcome the barriers. CONCLUSIONS We recommended strengthening Bangladesh's HIV/AIDS prevention, treatment, and management program with a special focus on the improvement of the supply chain of ART-related medicines and CD4 tests and ensuring proper counselling. In addition, we recommended strengthening the behaviour change communication and IEC activities at a large scale to destigmatize health facilities and community levels.
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Affiliation(s)
- Fariha Hossain
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor Darul Ehsan, Malaysia
| | | | | | - Devi Mohan
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor Darul Ehsan, Malaysia
| | - Sharuna Verghis
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor Darul Ehsan, Malaysia
| | - Nowrozy Kamar Jahan
- Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Selangor Darul Ehsan, Malaysia
- * E-mail:
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12
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Agaku I, Nkosi L, Gwar JN, Tsafa T. A cross-sectional analysis of U=U as a potential educative Intervention to mitigate HIV stigma among youth living with HIV in South Africa. Pan Afr Med J 2022; 41:248. [PMID: 35734331 PMCID: PMC9188005 DOI: 10.11604/pamj.2022.41.248.33079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/21/2022] [Indexed: 11/11/2022] Open
Abstract
Introduction the HIV educative campaign Undetectable Equals Untransmissible (U=U) is a potential gamechanger to address HIV stigma. We investigated what percentage of South African adolescents were aware of U=U, and the associations with perceived HIV stigma and past-year HIV testing. Methods we used a cross-sectional design. Data were from the 2017/2018 South African National HIV prevalence, incidence, behaviour and communication survey. HIV status was measured using both laboratory confirmation and self-reports. Among adolescents aged 15-18 years, we calculated the percentage who believed that "the risk of HIV transmission through sex can be reduced by an HIV-positive partner consistently taking drugs that treat HIV." Data were weighted to yield nationally representative estimates. Results overall, 49.8% of all adolescents aged 15-18 years (and 49.2% of this HIV seropositive) believed that the risk of HIV transmission through sex can be reduced by an HIV-positive partner consistently taking drugs that treat HIV. After adjusting for HIV status, geographic location, race, sex, and orphanhood status, those with belief in U=U were less likely to endorse stigmatizing statements that teachers with HIV should not teach (IRR=0.63, 95%CI, 0.47-0.84), pupils with HIV should not attend class (IRR=0.62, 95%CI, 0.45-0.84), or that children with HIV in general should be in segregated schools (IRR=0.55, 95%CI, 0.41-0.74). Among those reporting not living with HIV, U=U belief was associated with increased likelihood of past-year HIV testing (IRR=1.19, 95%CI, 1.01-1.41). Conclusion U=U belief was associated with reduced stigma perceptions and increased HIV testing. Adoption of U=U into clinical practice guidelines in South Africa may benefit public health.
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Affiliation(s)
- Israel Agaku
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, United States
| | - Lungile Nkosi
- Sefako Makgatho Health Sciences University (SMU), Pretoria, South Africa
| | | | - Tina Tsafa
- Department of Mass Communication, Benue State University, Makurdi, Nigeria
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Ahmed A, Dujaili JA, Jabeen M, Umair MM, Chuah LH, Hashmi FK, Awaisu A, Chaiyakunapruk N. Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan. Front Pharmacol 2022; 12:807446. [PMID: 35153763 PMCID: PMC8832364 DOI: 10.3389/fphar.2021.807446] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/20/2021] [Indexed: 01/30/2023] Open
Abstract
Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular. Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis. Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention. Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.
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Affiliation(s)
- Ali Ahmed
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
- Department of Pharmacy, Quaid-I-Azam University, Islamabad, Pakistan
- *Correspondence: Ali Ahmed, ; Juman Abdulelah Dujaili, ; Ahmed Awaisu,
| | - Juman Abdulelah Dujaili
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
- *Correspondence: Ali Ahmed, ; Juman Abdulelah Dujaili, ; Ahmed Awaisu,
| | - Musarat Jabeen
- ART Centre, Pakistan Institute of Medical Sciences (PIMS) Hospital, Islamabad, Pakistan
| | - Malik Muhammad Umair
- National AIDS Control Programme, National Institute of Health, Islamabad, Pakistan
| | - Lay-Hong Chuah
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
| | - Furqan Khurshid Hashmi
- University College of Pharmacy, University of the Punjab, Allama Iqbal Campus, Lahore, Pakistan
| | - Ahmed Awaisu
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Qatar University, Doha, Qatar
- *Correspondence: Ali Ahmed, ; Juman Abdulelah Dujaili, ; Ahmed Awaisu,
| | - Nathorn Chaiyakunapruk
- School of Pharmacy, Monash University, Subang Jaya, Malaysia
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, United States
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14
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Mulubale S, Clay S, Squire C, Bond V, Kasoka K, Stackpool-Moore L, Oraro-Lawrence T, Chonta M, Chiiya C. Situating HIV Stigma in Health Facility Settings: A Qualitative Study of Experiences and Perceptions of Stigma in 'Clinics' among Healthcare Workers and Service Users in Zambia. J Int Assoc Provid AIDS Care 2022; 21:23259582221100453. [PMID: 35570575 PMCID: PMC9121455 DOI: 10.1177/23259582221100453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The study focused on the representations, processes and effects of HIV stigma for
healthcare workers living with HIV within health facilities in Zambia. A
descriptive study design was deployed. A total of 56 health workers and four
service user participants responded to a structured questionnaire (n = 50) or
took part in key informant interviews (n = 10) in five high HIV-prevalence
provinces. Most participants did not disclose if they were living with HIV,
except for four participants who responded to the questionnaire and were
selected for being open about living with HIV. Semi-structured interviews were
carried out with health workers in key government health facility positions. The
questions were standardized and used a Likert scale. Descriptive statistical and
thematic analyses were applied to the data. Results show that antiretroviral
treatment (ART) has an impact on stigma reduction. Almost half the participants
agreed that treatment is reducing levels of HIV stigma. However, fears of
exposure of HIV status and labelling and judgemental attitudes persist. No
comprehensive stigma reduction policies and guidelines in healthcare facilities
were mentioned. Informal flexible systems to deliver HIV services were in place
for health workers living with HIV, illustrating how stigma can be quietly
navigated. Lack of confidentiality in healthcare facilities plays a role in
fuelling disclosure issues and hampering access to testing and treatment. Stigma
reduction training needs standardization. Further, codes of conduct for
‘stigma-free healthcare settings’ should be developed.
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Affiliation(s)
- Sanny Mulubale
- 108234The University of Zambia, MIET Africa, Lusaka, Zambia
| | - Sue Clay
- 3C Regional Consultancy, Lusaka, Zambia
| | - Corinne Squire
- School of Policy Studies, Bristol University, Bristol, England
| | - Virginia Bond
- London School of Hygiene and Tropical Medicine, London, UK.,503988Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
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15
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Tsai AC, Kakuhikire B, Perkins JM, Downey JM, Baguma C, Satinsky EN, Gumisiriza P, Kananura J, Bangsberg DR. Normative vs personal attitudes toward persons with HIV, and the mediating role of perceived HIV stigma in rural Uganda. J Glob Health 2021; 11:04956. [PMID: 34552725 PMCID: PMC8442577 DOI: 10.7189/jogh.11.04056] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background HIV stigma has well-documented negative impacts on HIV testing, transmission risk behavior, initiation of and adherence to antiretroviral therapy, and retention in care. We sought to assess the extent to which anticipated HIV stigma is based on misperceptions of normative attitudes toward persons with HIV, and to determine whether persons with HIV have stronger misperceptions compared with HIV-negative persons or persons of unknown serostatus. We also sought to estimate the association between normative attitudes about persons with HIV and personal attitudes about persons with HIV, and to determine the extent to which anticipated stigma mediates this association. Methods We conducted a whole-population survey of 1776 persons living in 8 rural villages in southwestern Uganda. Negative attitudes toward persons with HIV, and anticipated stigma, were measured using a newly validated 15-item scale measuring multiple dimensions of HIV stigma, including social distance, blaming attitudes, and concerns about reciprocity. We used multivariable regression to estimate the association between normative attitudes about persons with HIV and personal attitudes toward persons with HIV, and to determine the extent to which perceptions of normative attitudes (anticipated stigma) mediated this association. Results Study participants believed that negative attitudes toward persons with HIV were more pervasive than they actually are. Perceptions of the extent to which these negative attitudes are normative mediated more than one-third of the association between normative attitudes and their personal attitudes. In contrast to what we originally hypothesized, persons with HIV were less likely to misperceive these norms and perceived normative attitudes to be less stigmatizing than did others in the general population. Conclusions Interventions designed to accurately describe normative attitudes toward persons with HIV may reduce HIV stigma without directly focusing on the educational components that are typically embedded in anti-stigma interventions.
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Affiliation(s)
- Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Charles Baguma
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emily N Satinsky
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Justus Kananura
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - David R Bangsberg
- Mbarara University of Science and Technology, Mbarara, Uganda.,Oregon Health Sciences University-Portland State University School of Public Health, Portland, Oregon, USA
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16
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Hargreaves JR, Pliakas T, Hoddinott G, Mainga T, Mubekapi-Musadaidzwa C, Donnell D, Piwowar-Manning E, Agyei Y, Mandla NF, Dunbar R, Macleod D, Floyd S, Bock P, Fidler S, Hayes RJ, Seeley J, Stangl A, Bond V, Ayles H. HIV Stigma and Viral Suppression Among People Living With HIV in the Context of Universal Test and Treat: Analysis of Data From the HPTN 071 (PopART) Trial in Zambia and South Africa. J Acquir Immune Defic Syndr 2020; 85:561-570. [PMID: 32991336 PMCID: PMC7654947 DOI: 10.1097/qai.0000000000002504] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/05/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The impact of HIV stigma on viral suppression among people living with HIV (PLHIV) is not well characterized. SETTING Twenty-one communities in Zambia and South Africa, nested within the HPTN 071 (PopART) trial. METHODS We analyzed data on viral suppression (<400 copies HIV RNA/mL) among 5662 laboratory-confirmed PLHIV aged 18-44 years who were randomly sampled within the PopART trial population cohort 24 months after enrolment (PC24). We collected data on experiences and internalization of stigma from those PLHIV who self-reported their HIV status (n = 3963/5662) and data on perceptions of stigma from a 20% random sample of all PLHIV (n = 1154/5662). We also measured stigma at the community-level among PLHIV, community members, and health workers. We analyzed the association between individual- and community-level measures of HIV stigma and viral suppression among PLHIV, adjusting for confounding. RESULTS Of all 5662 PLHIV, 69.1% were virally suppressed at PC24. Viral suppression was highest among those 3963 cohort participants who self-reported living with HIV and were on ART (88.3%), and lower among those not on treatment (37.5%). Self-identifying PLHIV who reported internalized stigma were less likely to be virally suppressed (75.0%) than those who did not (80.7%; adjusted risk ratio, 0.94 95% CI: 0.89 to 0.98). Experiences, perceptions, and community-level measures of stigma were not associated with viral suppression. CONCLUSION Internalized stigma among PLHIV was associated with a lower level of viral suppression; other dimensions of stigma were not. Stigma reduction approaches that address internalized stigma should be an integral component of efforts to control the HIV epidemic.
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Affiliation(s)
- James R. Hargreaves
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Tila Mainga
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Constance Mubekapi-Musadaidzwa
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | | | | | - Yaw Agyei
- Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nomhle F. Mandla
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Rory Dunbar
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - David Macleod
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sian Floyd
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Peter Bock
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sarah Fidler
- Imperial College NIHR BRC, Imperial College London, London, United Kingdom; and
| | - Richard J. Hayes
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Janet Seeley
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anne Stangl
- International Center for Research on Women, Washington, DC
| | - Virginia Bond
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
| | - Helen Ayles
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Zambart, School of Medicine, University of Zambia, Lusaka, Zambia
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"It's because I think too much": Perspectives and experiences of adults with hypertension engaged in HIV care in northern Tanzania. PLoS One 2020; 15:e0243059. [PMID: 33270765 PMCID: PMC7714125 DOI: 10.1371/journal.pone.0243059] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 11/13/2020] [Indexed: 12/13/2022] Open
Abstract
Background Hypertension, a leading risk for cardiovascular mortality, is an important co-morbidity among people living with HIV (PLHIV). In Tanzania, hypertension prevalence among PLHIV approaches 20 to 30%. However, most patients are unaware of their diagnosis and are not receiving treatment. Understanding the barriers to hypertension care is a critical first step in developing interventions to improve cardiovascular outcomes among PLHIV in Tanzania and similar settings. Methods Between September 1st and November 26th, 2018 thirteen semi structured in-depth interviews were conducted with hypertensive patients engaged in HIV care in two HIV clinics located in government health facilities in northern Tanzania. Interviews were audio-recorded, translated into English, transcribed and thematically coded using NVivo. Data analysis was conducted using applied thematic analysis. Results Participants had a median age of 54 (IQR 41–65) years. Of the 13 participants, eight stated they had used antihypertensive medication previously, but only one participant described current use of antihypertensive therapy. All participants were currently using antiretroviral therapy. The data revealed a range of themes including limited hypertension knowledge. Universally, all participants believed that “thinking too much”, i.e. stress, was the major contributor to hypertension and that by “reducing thoughts”, one may control hypertension. Additional emerging themes included a perceived overlap between hypertension and HIV, delays in hypertension diagnosis and linkage to care, challenges with provider communication and counseling, reluctance towards antihypertensive medication, lack of integration of hypertension and HIV care, and additional structural barriers to hypertension care. Conclusions Participants described multiple, intersecting challenges related to hypertension management. Barriers specific to PLHIV included siloed care, HIV-related stigma, and burden from multiple medical conditions. Multifaceted strategies that seek to address structural barriers, hypertension education, psychosocial stressors and stigma, and that are integrated within HIV care are urgently needed to improve cardiovascular outcomes among PLHIV in sub-Saharan Africa.
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