Refused and referred-persistent stigma and discrimination against people living with HIV/AIDS in Bihar: a qualitative study from India

Assessing the current situation and the influencing factors affecting perceived stigma among older patients after leukemia diagnosis

BACKGROUND

Psychological problems are becoming increasingly prominent among older patients with leukemia, with patients potentially facing stigmatization after diagnosis. However, there is limited research on the stigma experienced by these patients and the factors that may contribute to it.

AIM

To investigate the stigma faced by older patients after being diagnosed with leukemia and to analyze the potential influencing factors.

METHODS

A retrospective analysis was conducted using clinical data obtained from questionnaire surveys, interviews, and the medical records of older patients with leukemia admitted to the Hengyang Medical School from June 2020 to June 2023. The data obtained included participants’ basic demographic information, medical history, leukemia type, family history of leukemia, average monthly family income, pension, and tendency to conceal illness. The Chinese versions of the Social Impact Scale (SIS), Perceived Social Support Scale (PSSS), Self-Rating Anxiety Scale (SAS), and Self-Rating Depression Scale (SDS) were used to assess indicators related to stigma, social support, and mental health status. We used Pearson’s correlation coefficient to analyze the strength and direction of the relationship between the scores of each scale, and regression analysis to explore the factors related to the stigma of older patients with leukemia after diagnosis.

RESULTS

Data from 120 patients with leukemia aged 65-80 years were analyzed. The total score on the SIS and PSSS was 43.60 ± 4.07 and 37.06 ± 2.87, respectively. The SAS score was 58.35 ± 8.32 and the SDS score was 60.58 ± 5.97. The stigma experienced by older leukemia patients was negatively correlated with social support (r = -0.691, P < 0.05) and positively correlated with anxiety and depression (r = 0.506, 0.382, P < 0.05). Age, education level, smoking status, average monthly family income, pension, and tendency to conceal illness were significantly associated with the participants’ level of stigma (P < 0.05). Age, smoking status, social support, anxiety, and depression were predictive factors of stigmatization among older leukemia patients after diagnosis (all P < 0.05), with a coefficient of determination (R²) of 0.644 and an adjusted R² of 0.607.

CONCLUSION

Older patients commonly experience stigmatization after being diagnosed with leukemia. Factors such as age, smoking status, social support, and psychological well-being may influence older patients’ reported experience of stigma.

Development and validation of the perceived symptom manageability scale among people living with the human immunodeficiency virus

BACKGROUND

"Perceived Symptom Manageability (PSM)" is essential in symptom management among people living with HIV. As a standardized assessment instrument was lacking, we developed a PSM scale for people living with human immunodeficiency virus (PSM-HIV).

METHODS

Data analysis was performed using the sample from HIV-designated medical institutions (N = 540). Psychometric testing, namely reliability and validity, is assessed by unidimensionality, internal consistency, exploratory and confirmatory factor analysis, and structural equation modeling.

RESULTS

The final version of the PSM- HIV scale contained 15 items. This scale was submitted to a principal components analysis with varimax rotation, and three factors were obtained, explained by a total variance of 63.10%. The three factors were named Cognitive-Behavioral, Affective Interaction, and Self-Attitude. The results show that the scale had high reliability, Cronbach's α of the scale ranged from 0.71 to 0.92, and the Intraclass Correlation Coefficient was 0.88. The structural equation model supports a factor model with the acceptable fit (χ2/df (CMIN/DF) = 2.50, Root Mean square Residual (RMR) = 0.03, Goodness-of-Fit Index (GFI) = 0.93, Adjusted Goodness of Fit Index (AGFI) = 0.90, Normed Fit Index (NFI) = 0.93, Incremental Fit Index (IFI) = 0.96, Comparative Fit Index (CFI) = 0.96). The average variance extracted was 0.38 ∼ 0.59, and the composite reliability was 0.70 ∼ 0.91, indicating that the convergent validity of the scale is acceptable. Subjects with different stages of the disease reached significance(χ2 = 9.02; df = 2, P<0.05), meaning moderate Known-Groups Comparison Validation.

CONCLUSIONS

The PSM-HIV scale is a valid instrument that measures overall attitude and belief about controlling or coping with HIV-relevant symptoms.

Sexually transmitted infection (STI) knowledge and perceptions among people in HIV-sero-different partnerships in rural southwestern Uganda

Globally, over one million people acquire curable sexually transmitted infections (STI) each day. Understanding how people think about STIs is key to building culturally appropriate STI prevention and treatment programs. We explored STI knowledge and perceptions in rural, southwestern Uganda to inform future interventions. From August 2020 to December 2020, we conducted individual in-depth interviews among adult men and women (≥18 years) with recent or current personal or partner pregnancy, a history of an STI diagnosis and treatment, and membership in an HIV-sero-different relationship. Interviews explored STI knowledge, perceptions, and barriers and facilitators to engaging in STI care. We used inductive and deductive approaches to generate a codebook guided by the healthcare literacy skills framework in a thematic analysis. Ten men with STI, five of their female partners, eighteen women with STI, and four of their male partners participated in individual in-depth interviews. The median age was 41 (range 27-50) for men and 29 (range 22-40) for women. Sixteen (43%) participants were with HIV. Significant themes include: 1) Participants obtained STI knowledge and information from the community (friends, family members, acquaintances) and medical professionals; 2) While participants knew STIs were transmitted sexually, they also believed transmission occurred via non-sexual mechanisms. 3) Participants associated different connotations and amounts of stigma with each STI, for example, participants reported that syphilis was passed down "genetically" from parent to child. 4) Participants reported uncertainty about whether STIs affected pregnancy outcomes and whether antenatal STI treatment was safe. The complicated nature of STIs has led to understandable confusion in settings without formal sexual healthcare education. Robust counseling and education prior to sexual debut will help allow men and women to understand the signs, symptoms, and treatments necessary for STI cure and to navigate often complicated and overburdened healthcare systems.

Sociodemographic correlates of discrimination against PLHIV in High HIV prevalence states of India, NFHS 2016-21

This study investigates the socio-demographic correlates of HIV discrimination among individuals aged 15-49 years. This study also aims to assess the change in discriminatory attitudes towards PLHIV in high HIV prevalence states from 2016 to 2021 using data from the national Demographic Health Survey (4th and 5th). To identify factors associated with discriminatory attitudes, a multivariable logistic regression analysis was performed. Further, predicted probabilities and average marginal effects were computed, and the difference in discriminatory attitudes across both rounds was examined using a non-linear Fairlie decomposition. Mass media exposure, improved wealth index, and comprehensive knowledge significantly reduced the discriminatory attitudes towards PLHIV. Fairlie decomposition indicated that comprehensive knowledge, knowledge of mother-to-child transmission, and mass media exposure was significant contributor to the differences observed in the discriminatory attitude towards PLHIV across survey rounds. This study emphasizes the importance of spreading accurate information about HIV transmission modes and reinforces existing programmes and policies aimed at reducing stigma and discrimination against PLHIV. These programmes' efficiency and effectiveness can be ensured by linking them with community-level programmes and activities organized by Self Help Groups (SHGs), which have resulted in a paradigm shift in empowering women in India.

Empowering families to take on a palliative caregiver role for patients with cancer in India: Persistent challenges and promising strategies

BACKGROUND

The population of patients with cancer requiring palliative care (PC) is on the rise in India. Family caregivers will be essential members of the care team in the provision of PC.

OBJECTIVE

We aimed to characterize provider perspectives of the challenges that Indian families face in taking on a palliative caregiving role.

METHOD

Data for this analysis came from an evaluation of the PC-PAICE project, a series of quality improvement interventions for PC in India. We conducted 44 in-depth semi-structured interviews with organizational leaders and clinical team members at seven geographically and structurally diverse settings. Through thematic content analysis, themes relating to the caregivers' role were identified using a combination of deductive and inductive approaches.

RESULT

Contextual challenges to taking up the PC caregiving role included family members' limited knowledge about PC and cancer, the necessity of training for caregiving responsibilities, and cultural preferences for pursuing curative treatments over palliative ones. Some logistical challenges include financial, time, and mental health limitations that family caregivers may encounter when navigating the expectations of taking on the caregiving role. Strategies to facilitate family buy-in for PC provision include adopting a family care model, connecting them to services provided by Non-Governmental Organizations, leveraging volunteers and social workers to foster PC awareness and training, and responding specifically to family's requests.

CONCLUSION

Understanding and addressing the various challenges that families face in adopting the caregiver role are essential steps in the provision and expansion of PC in India. Locally initiated quality improvement projects can be a way to address these challenges based on the context.

Development of shortened HIV-related stigma scales for young people living with HIV and young people affected by HIV in India

BACKGROUND

HIV-related stigma is associated with poor quality of life and poor healthcare-seeking behaviours in young people living with HIV (YPLHIV) and young people affected by HIV (YPAHIV). India has an estimated 120,000 YPLHIV and 4 million YPAHIV, but efforts to measure HIV-related stigma in them are sparse, impeded by the lack of measuring instruments. Here, we describe the development of the Pune HIV-Stigma Scale (PHSS) and modified-PHSS to measure HIV-related stigma among YPLHIV and YPAHIV, respectively, in India.

METHODS

We used data from a mental health study for YPLHIV and YPAHIV aged 15-25 years, conducted at Byramjee Jeejeebhoy Government Medical College & Sassoon General Hospitals, Pune, India, between August 2018 and June 2021. Findings from multiple confirmatory factor analyses and cognitive interviews guided the development of the 12-item PHSS. The modified-PHSS was developed by confirming the structure of the PHSS for YPAHIV. Convergent validity with Center for Epidemiological Studies Depression (CES-D) and UCLA Loneliness scales was assessed using Spearman's correlation coefficients.

RESULTS

Model fit indices were good for both the PHSS (χ² = 65.0, df = 48, p value: 0.052; root mean square error of approximation (RMSEA): 0.054; comparative fit index (CLI): 0.980; Tucker-Lewis index (TLI): 0.972; and standardized root mean square residual (SRMR): 0.067), and the modified-PHSS (χ² = 56.9, df = 48, p value: 0.176; RMSEA: 0.045; CLI: 0.983; TFI: 0.976, and SRMR: 0.078). Spearman's correlation coefficients indicated low to moderate convergent validity (ρ: 0.03-0.52) across different subscales of the PHSS and modified-PHSS. Cronbach's alpha for the PHSS was 0.82 and for the modified-PHSS 0.81.

CONCLUSION

We developed the first scales to measure HIV-related stigma among YPLHIV and YPAHIV in India. These concise scales can facilitate measurement of HIV-related stigma more frequently in research studies. We recommend that they be tested in different Indian languages.

Determinants Model in Reducing HIV-Related Stigma in Health care Workers: A Systematic Review

Background: The stigma accepted by people living with HIV (PLWHA) is a major obstacle in HIV prevention, especially from health workers. Aims: This study aims to determine the factors associated with HIV stigma among health workers. Methods: This systematic review was conducted using the 2015 PRISMA guidelines. All publications by reading the title and abstract. In the final screening stage, the authors read the full text of the remainder of the article and held back studies that were consistent with inclusion criteria, focusing on HIV-related stigma determinants published in 2010-2020. Results: The stigma that comes from health workers to PLWHA can come from personal beliefs or a lack of personal confidence, which can be derived from self-confidence, self-confidence, knowledge, working time, and institutional support or policies from the workplace that create discriminatory behavior when dealing with PLWHA. The created stigma can reduce social interactions and the quality of life of PLWHA. Conclusion: It is important to find determinants to formulate appropriate intervention plans in reducing HIV-related stigma, especially among health workers.

Approaching Sexually Transmitted Infections in a Nursing Undergraduate Curriculum

OBJECTIVE

To identify the approach to sexually transmitted infections in the undergraduate nursing course at a federal university in southern Brazil.

METHOD

Socio-historical research with a qualitative approach, and use of oral and documentary sources. Thirteen professors participated. Data collection took place between December 2018 and April 2019. Data analysis was thematic.

RESULTS

Three categories of analysis emerged: the teaching of sexually transmitted infections based on Brazilian public policies; sexually transmitted infections and their teaching strategy in an undergraduate nursing course; and the trajectory of approach to sexually transmitted infections in an undergraduate nursing course. The undergraduate course is based on public health and education policies, and the subject "Sexually Transmitted Infections" was created in the course at the end of the 1970s. The content is not mandatory, being associated with the area of public health and evidenced in the fields of practice and educational activities.

CONCLUSION

The teaching of sexually transmitted infections has been in line with public health and education policies. It gains a greater teaching focus with the emergence of AIDS.

Improving public health service delivery response to address contraceptive needs of socio-economically disadvantaged HIV positive people in Maharashtra, India

Background

People living with HIV (PLHIV) receive free antiretroviral treatment (ART) in public health facilities of India. With improved life expectancy, unmet sexual and reproductive health needs of PLHIV have to be addressed through a converged programmatic response strategy. Evidence shows that socioeconomically disadvantaged women are most vulnerable to high reproductive morbidities, especially HIV positive women with an unmet need of contraception.

Methods

Programmatic convergence by linking ART and family planning services were strengthened at two public health facilities (district hospitals) generally accessed by disadvantaged socio-economic sections of the society. Barriers to linking services including stigma and discrimination were addressed through analysis of existing linkage situation, sensitization and training of healthcare providers and system-level interventions. This facilitated provider-initiated assessment of contraceptive needs of PLHIV, counseling about dual contraception using a couple approach, linkage to family planning centers and maintaining data about these indicators. Six hundred eligible PLHIV seeking care at ART centers were enrolled and followed up for a duration of 6 months. Acceptance of family planning services as a result of the intervention, use of dual contraception methods and their determinants were assessed.

Results

Eighty-seven percent HIV couples reached FP centers and 44.6% accepted dual methods at the end of the study period. Dual methods such as oral contraceptive pills (56.2%), IUCDs (19.4%), female sterilization (11.6%), injectable contraception (9.9%) and vasectomy (2.9%) in addition to condoms were the most commonly accepted methods. Condom use remained regular and consistently high throughout. The study witnessed seven unintended pregnancies, all among exclusive condom users. These women availed medical abortion services and accepted dual methods after counseling. Female index participants, concordant couples, counseling by doctors and women with CD4 count above 741 had higher odds of accepting dual contraception methods. Standard operating procedures (SOP) were developed in consultation with key stakeholders to address operational linkage of HIV and family programs.

Conclusion

The study saw significant improvement in acceptance of dual contraception by PLHIV couples as a result of the intervention. Implementation of SOPs with supportive supervision can ensure efficient linkage of programs and provide holistic sexual and reproductive healthcare for PLHIV in India.

Effect of peer education model on nursing students' knowledge and attitudes towards HIV/AIDS

OBJECTIVES

This research is an intervention study designed as a single group pre-test post-test model without control group in order to examine the effect of education provided to nursing students based on peer education model on HIV/AIDS knowledge level and attitude.

DESIGN, METHODS, SETTINGS AND PARTICIPANTS

The research was carried out at Nursing Department of Ankara Yıldırım Beyazıt University. Sample of the study consisted of second year nursing students who agreed to participate in the study and enrolled Internal Medicine Nursing course for the first time (n = 88). In the first stage of the study, nine peer mentors were selected and a total of 12 h of training were given to them by the researchers. In the second stage, peer mentors provided a total of 12 h of training to nine peer students groups. All groups were created by simple randomization on the "research randomizer" website. Demographics questionnaire, AIDS knowledge scale and AIDS attitude scale were used to collect the data. Data was analyzed by using descriptive statistics, Pearson Chi-square test, paired sample t-Test, Wilcoxon test and Spearman correlation test.

RESULTS

It was determined that peer education provided a statistically significant increase in AIDS knowledge scale score in peer students (pretest x¯=10.32 ± 3.59, posttest x¯=19.69 ± 1.51) (p < 0.001). In addition, peer education was found to provide a statistically significant increase in AIDS attitude scale score in peer students (pretest x¯=56.64 ± 8.36, posttest x¯=72.95 ± 7.02) (p < 0.001).

CONCLUSION

It has been determined that peer education method is an effective method in increasing HIV/AIDS knowledge and attitude towards people living with HIV/AIDS in nursing students. Therefore, it is recommended to include peer education model in nursing educations regarding HIV/AIDS.

Reduction in Stigma Drivers Partially Mediates the Effect of a Stigma Reduction Intervention Among Nursing Students in India: The DriSti Cluster Randomized Controlled Trial

BACKGROUND

HIV stigma in health care settings acts as a significant barrier to health care. Stigma drivers among health professionals include transmission fears and misconceptions and pre-existing negative attitudes toward marginalized groups vulnerable to HIV. The DriSti intervention, consisted of 2 sessions with videos and interactive exercises on a computer tablet and one interactive face-to-face group session, mostly tablet administered, was designed to target key stigma drivers that included instrumental stigma, symbolic stigma, transmission misconceptions and blame to reduce HIV stigma, and discrimination among nursing students (NS) and ward staff and tested in a cluster randomized trial.

SETTING

This report focuses on second and third year NS recruited from a range of nursing schools that included private, nonprofit, and government-run nursing schools in south India.

RESULTS

Six hundred seventy-nine NS received intervention and 813 NS were in the wait-list control group. Twelve months outcome analyses showed significant reduction among intervention participants in endorsement of coercive policies (P < 0.001) and in the number of situations in which NS intended to discriminate against PLWH (P < 0.001). Mediation analysis revealed that the effects of intervention on endorsement of coercive policies and intent to discriminate against PLWH were partially mediated by reductions in key stigma drivers.

CONCLUSIONS

This brief scalable stigma reduction intervention targeting key stigma drivers fills a critical gap in identifying the mechanistic pathways that aid in stigma reduction among health professionals.

HIV-Related Stigma Reduction in the Era of Undetectable Equals Untransmittable: The South Korean Perspective

Since the introduction of effective antiretroviral therapy (ART) in the late 1990s, the prognosis for people living with human immunodeficiency virus (HIV) (PLWH) has dramatically improved. High-income countries like South Korea have had rapid declines in HIV-related deaths. Scientific advancements including pre-exposure prophylaxis (PrEP) and “undetectable equals untransmittable (U = U)” knowledge have contributed progress towards the goal of ending the acquired immune deficiency syndrome epidemic by 2030. However, the application of these advancements has been limited in South Korea. Evidence shows that HIV-related stigma and discrimination in healthcare settings remain strong in this region. We review key principles for stigma reduction and people-centered approaches in the era of U = U and identify three priorities: 1) immediate intervention in HIV stigma drivers in healthcare settings; 2) social stigma reduction on multiple levels; and 3) collaboration with key populations.

Lived experiences of palliative care among people living with HIV/AIDS: a qualitative study from Bihar, India

OBJECTIVES

This study aimed to assess the lived experiences of palliative care among critically unwell people living with HIV/AIDS (PLHA), caregivers and relatives of deceased patients. It also aimed to understand the broader palliative care context in Bihar.

DESIGN

This was an exploratory, qualitative study which used thematic analysis of semistructured, in-depth interviews as well as a focus group discussion.

SETTING

All interviews took place in a secondary care hospital in Patna, Bihar which provides holistic care to critically unwell PLHA.

PARTICIPANTS

We purposively selected 29 participants: 10 critically unwell PLHA, 5 caregivers of hospitalised patients, 7 relatives of deceased patients who were treated in the secondary care hospital and 7 key informants from community-based organisations.

RESULTS

Critically ill PLHA emphasised the need for psychosocial counselling and opportunities for social interaction in the ward, as well as a preference for components of home-based palliative care, even though they were unfamiliar with actual terms such as 'palliative care' and 'end-of-life care'. Critically unwell PLHA generally expressed preference for separate, private inpatient areas for end-of-life care. Relatives of deceased patients stated that witnessing patients' deaths caused trauma for other PLHA. Caregivers and relatives of deceased patients felt there was inadequate time and space for grieving in the hospital. While both critically ill PLHA and relatives wished that poor prognosis be transparently disclosed to family members, many felt it should not be disclosed to the dying patients themselves.

CONCLUSIONS

Despite expected high inpatient fatality rates, PLHA in Bihar lack access to palliative care services. PLHA receiving end-of-life care in hospitals should have a separate dedicated area, with adequate psychosocial counselling and activities to prevent social isolation. Healthcare providers should make concerted efforts to inquire, understand and adapt their messaging on prognosis and end-of-life care based on patients' preferences.

Experiences of stigma in healthcare settings by people living with HIV in Ireland: a qualitative study

Stigma in healthcare settings remains a barrier to accessing screening, treatment and care for HIV and is a driver of the global HIV epidemic. This study examined the stigma experiences in healthcare settings of people living with HIV (PLHIV) in Ireland. Semi-structured interviews were carried out with 4 women and 10 men living with HIV. Data were analysed using a Directed Content Analysis approach to assess experiences of enacted, anticipated and internalised stigma. The findings indicate experiences of enacted, anticipated and internalised stigma were common. A further finding of spatial stigma was also uncovered. Analysis showed these experiences impacted participants' engagement with care and affected health-seeking behaviours and treatment adherence. The results suggest stigma experienced in healthcare settings may impact negatively on health outcomes.