Understanding disclosure behaviours in HIV-positive young people

Experiences of adolescents and youth with HIV testing and linkage to care through the Red Carpet Program (RCP) in Kenya

Adolescents and youth living with HIV (AYLHIV) experience worse health outcomes compared to adults. We aimed to understand the experiences of AYLHIV in care in the youth-focused Red-Carpet program in Kenya to assess the quality of service provision and identify programmatic areas for optimization. We conducted focus group discussions among 39 AYLHIV (15-24 years) and structured analysis into four thematic areas. Within the HIV testing theme, participants cited fear of positive results, confidentiality and stigma concerns, and suggested engaging the community and youth in HIV testing opportunities. Within the HIV treatment adherence theme, participants cited forgetfulness, stigma, adverse side effects, lack of family support, and treatment illiteracy as barriers to adherence. Most participants reported positive experiences with healthcare providers and peer support. In terms of the HIV status disclosure theme, AYLHIV cited concerns about their future capacity to conceive children and start families and discussed challenges with understanding HIV health implications and sharing their status with friends and partners. Youth voices informing service implementation are essential in strengthening our capacity to optimize the support for AYLHIV within the community, at schools and healthcare facilities.

Socioeconomic inequality, health inequity and well-being of transgender people during the COVID-19 pandemic in Nigeria

BACKGROUND

We aimed to explore socioeconomic inequality, health inequity, and the well-being of transgender people during the COVID-19 crisis in Nigeria.

METHODS

Between June and December 2021, a cross-sectional survey was conducted collaboratively with community-based organisations in Nigeria. Participants living with or at risk of HIV were recruited voluntarily, online and face-to-face, using a combination of venue-based and snowball sampling. We assessed the association between gender identity (transgender and vulnerable cisgender women), and (i) socioeconomic inequality measured with socioeconomic status, social status, economic vulnerability, macrosocial vulnerability; (ii) health inequity measured with self-assessment of health, recency of HIV test, access to HIV and sexual and reproductive health services, gender-affirming care, financial and non-financial barriers to accessing health services; and (iii) well-being, measured with gender-based violence, mental health, psychoeconomic preferences. We used multivariable logistic regressions and controlled for interactions and confounders.

RESULTS

There were 4072 participants; 62% were under 30, and 47% reported living with HIV. One in ten (11.9%; n = 485) was transgender, and 56.5% reported living with HIV. Compared to vulnerable cisgender women, the results showed significantly higher odds (aOR:3.80) of disruption in accessing HIV services in transgender participants; gender-based violence (aOR:2.63); severe (aOR:2.28) symptoms of anxiety and depression. Among the barriers to accessing health and HIV services, transgender had three-time higher odds of reporting additional non-official fees compared to vulnerable cisgender women. The disclosure of their gender identity or sexual orientation was the most important non-financial barrier to accessing health services (aOR:3.16). Transgender participants faced higher housing insecurity (aOR: 1.35) and lower odds of using drugs (aOR:0.48). Importantly, they are more likely to have performed a recent HIV test and less likely to not know their HIV status (aOR:0.38) compared to vulnerable cisgender women.

CONCLUSIONS

Socioeconomic inequality, health and well-being inequity in transgender people appear to be exacerbated by the COVID-19 pandemic in Nigeria. Interventions are necessary to mitigate socioeconomic challenges, address structural inequality, and ensure equitable access to health services to meet the Sustainable Development Goals for transgender people.

"We can tell a good teacher who cares, understands, and can be confidential about it": youth and caregiver experiences with HIV disclosure to schools in Kenya

Introduction

Disclosure of one's HIV status to others is often difficult due to the fear of stigma. However, disclosure may facilitate receiving social support. Many youth living with HIV (YLH) are enrolled in school as better treatments have improved the health and survival of children with HIV. There is no structured process for disclosure at school for YLH and their caregivers. We sought to understand school disclosure experiences among YLH and their caregivers and assess the need for the development of a structured disclosure intervention tailored to school settings.

Methods

We conducted in-depth qualitative interviews with 28 school-going YLH aged 14-19 years and 24 caregivers of YLH. Interviews were conducted in English and Swahili, transcribed, and translated. The transcripts were uploaded to Atlas.ti 9 for thematic analysis.

Results

YLH and caregivers clearly articulated the benefits of disclosing to school staff. Disclosure to school staff was seen as the first step to receiving support for medication storage, adherence, and clinic attendance. However, disclosure was also perceived to be a very complicated and stressful process. Fear of stigma drove caregivers and YLH toward careful planning of when and to whom to disclose. Distrust of school staff was a significant barrier to disclosure, even among those who clearly articulated the benefits of disclosure. Disclosure to school staff largely resulted in positive experiences; the immediate reactions were positive or somewhat neutral and confidentiality was upheld. The anticipated benefits of practical and emotional support were demonstrated by the school staff to whom the HIV information was disclosed.

Conclusion

Disclosure of HIV status to someone at school is necessary to receive support for medication adherence. Stigma and the lack of structured support for the disclosure process at school often hinder YLH and their caregivers from disclosing. YLH would benefit from better support at schools, including policies to facilitate disclosure that address the caregiver and YLH's fear of stigma and loss of confidentiality. School policies could also provide guidance on whom to disclose to and available post-disclosure support.

Characteristics of mental health interventions in a cohort of Italian PLWH over the last five years: impact of HIV disease and outbreak of COVID-19 pandemic

Evidence accumulated during past years confirm that people living with HIV (PLWH) still have to deal with comorbidities and chronic complications that can increase physical and psychological issues and can affect daily functioning, quality of life and mental health. Moreover, during the COVID-19 pandemic PLWH proved to be a population at increased risk of psychological distress. We explored the ongoing issues and the characteristics of the mental health interventions for which a cohort of Italian PLWH interacted with a psychologist over the past five years. We analysed a dataset that included 61 PLWH who underwent a psychological intervention between 2018 and 2022. We compared different frequencies in characteristics of mental health interventions according to different demographic and clinical variables, psychopathological symptoms and time of the request for intervention. We showed that psychopathological symptoms most frequently reported by patients were anxiety (55.7%), and depression (49.2%). Furthermore, we reported that most our patients undertook occasional psychological support meetings (31%), sought an intervention after the outbreak of the COVID-19 pandemic (62.3%) and complained about disclosure issues (48.5%). Disclosure issues were mainly reported by younger PLWH (p = 0.002) with a shorter disease (p = 0.031) and treatment history (p = 0.032), and higher interpersonal sensitivity (p = 0.042). It seems fundamental to integrate psychological interventions into the care of PLWH, to give particular attention to PLWH with risky demographic, clinical and mental health factors and to pay special attention to emergency conditions (such as the COVID-19 pandemic) and the most widespread issues to create ad hoc interventions.

School-level Barriers of Antiretroviral Therapy Adherence and Interventions to Overcome them Among Adolescents Living with HIV in Western Kenya: A Qualitative Study

Background:

Adolescents in Kenya spend the majority of their time in a school environment. However, research to understand Antiretroviral Therapy (ART) adherence among adolescents living with HIV (ALWHIV) in school settings is sparse.

Objective:

To improve the design of appropriate interventions to better support this vulnerable population, the study aimed to explore school-related barriers to ART adherence experienced by ALWHIV.

Methods:

Qualitative data were utilized from a larger mixed-methods study on ALWHIV conducted at a major teaching and referral hospital in Kisumu, Kenya. Participants encompassed ALWHIV, their caregivers, teachers, and health care providers. Transcripts from a total of 24 in-depth interviews and five focus group discussions were analyzed in NVivo using a thematic approach.

Results:

Four themes emerged as key barriers in a school setting: negative experiences following HIV status self-disclosure, a strong desire for secrecy, restrictive school policies, and health education focused on sexual transmission of HIV. Participants suggested a range of potential interventions to better support ART adherence for ALWHIV, including coaching ALWHIV on disclosure strategies, promoting empathy among teachers and students, transition-preparing for ALWHIV, changing the narrative about HIV transmission in schools, providing water in schools, and introducing adherence support programs in schools, including the use of mobile technology.

Conclusion:

ALWHIV in Kenya experience numerous important challenges while trying to maintain optimal ART adherence in the school environment. Interventions that create supportive school settings are critical for better health outcomes among ALWHIV.

Living With a Stigmatized Identity; Perceptions of Disclosure, Coping, and Medication Adherence Among Adolescent Boys and Young Men in Chiredzi-Zimbabwe

There is limited research on adolescent boys and young men (ABYM)'s initial and onward HIV seropositive status disclosure, coping strategies and treatment adherence journeys especially in Zimbabwe. This qualitative exploratory study employed in-depth individual interviews at Chiredzi General Hospital in Zimbabwe to explore the dynamics of disclosure, coping and treatment adherence among ABYM. Twenty-one HIV positive ABYM with ages ranging from 14 to 21 were recruited from their scheduled visit to collect medication at the hospital. Findings indicate that ABYM disclosure journeys began with shock, confusion or misunderstanding and ended in a positive life outlook. Treatment adherence among ABYM was very poor due to poverty, erratic food supply, feeling sick after taking medication, forgetfulness and the public nature of medication collection centers. The study concluded that ABYM maintained secrecy in order to be accepted by their peers but also to protect themselves from stigma and isolation.

24-Month Clinical, Immuno-Virological Outcomes, and HIV Status Disclosure in Adolescents Living With Perinatally-Acquired HIV in the IeDEA-COHADO Cohort in Togo and Côte d'Ivoire, 2015-2017

Background: Adolescents living with perinatally-acquired HIV (APHIV) face challenges including HIV serostatus disclosure. We assessed their 24-month outcomes in relation to the disclosure of their own HIV serostatus. Methods: Nested within the International epidemiologic Database to Evaluate AIDS pediatric West African prospective cohort (IeDEA pWADA), the COHADO cohort included antiretroviral (ART)-treated APHIV aged 10-19 years, enrolled in HIV care before the age of 10 years, in Abidjan (Côte d'Ivoire) and Lomé (Togo) in 2015. We measured the HIV serostatus disclosure at baseline and after 24 months and analyzed its association with a favorable combined 24-month outcome using logistic regression. The 24-month combined clinical immuno-virological outcome was defined as unfavorable when either death, loss to follow-up, progression to WHO-AIDS stage, a decrease of CD4 count >10% compared to baseline, or a detectable viral load (VL > 50 copies/mL) occurred at 24 months. Results: Overall, 209 APHIV were included (51.6% = Abidjan, 54.5% = females). At inclusion, the median CD4 cell count was 521/mm 3 [IQR (281-757)]; 29.6% had a VL measurement, of whom, 3.2% were virologically suppressed. APHIV were younger in Lomé {median age: 12 years [interquartile range (IQR): 11-15]} compared to Abidjan [14 years (IQR: 12-15, p = 0.01)]. Full HIV-disclosure increased from 41.6% at inclusion to 74.1% after 24 months. After 24 months of follow-up, six (2.9%) died, eight (3.8%) were lost to follow-up, and four (1.9%) were transferred out. Overall, 73.7% did not progress to the WHO-AIDS stage, and 62.7% had a CD4 count above (±10%) of the baseline value (48.6% in Abidjan vs. 69.0% in Lomé, p < 0.001). Among the 83.7% with VL measurement, 48.8% were virologically suppressed (Abidjan: 45.4%, Lomé: 52.5%, p <0.01). The 24-month combined outcome was favorable for 45% (29.6% in Abidjan and 61.4% in Lomé, p < 0.01). Adjusted for baseline variables, the 24-month outcome was worse in Lomé in those who had been disclosed for >2 years compared to those who had not been disclosed to [aOR = 0.21, 95% CI (0.05-0.84), p = 0.03]. Conclusions: The frequency of HIV-disclosure improved over time and differed across countries but remained low among West African APHIV. Overall, the 24-month outcomes were poor. Disclosure before the study was a marker of a poor 24-month outcome in Lomé. Context-specific responses are urgently needed to improve adolescent care and reach the UNAIDS 90% target of virological success.

90 DAYS: An investigation of a short entertainment-education film to improve HIV status disclosure among black women living with HIV in Miami-Dade County

Within Miami-Dade County, Black women experience disproportionate rates of HIV incidence and prevalence. Status disclosure to sexual partners is central to mitigating the HIV epidemic and ensuring a healthier lifestyle for those living with the virus. The disclosure processes model (DPM) posits that barriers such as stigma and negative outcome expectations often facilitate disclosure avoidance. Therefore, this study investigated the utility and acceptability of an entertainment-education (EE) short film, 90 DAYS, for disclosure among Black women living with HIV in Miami-Dade County. Employing photo-elicitation (Harper, 2002), focus groups were conducted with 48 participants. After screening the 90 DAYS film about stigma and disclosure, participants were asked semi-structured questions based upon extant EE and DPM literature. Via inductive and deductive processes, five themes were derived from the data. Participants found the 90 DAYS film to be an empowering counter-narrative that could be used to overcome multiple disclosure-related factors. They felt it provided a social script for how to disclose to their sexual partners. A novel finding of this investigation was that respondents asserted the film could facilitate safer disclosure events. Additional themes included the film being a resource of hope for young and newly diagnosed women; and an educational tool for the community. Altogether, findings lend promise to the use of EE for addressing disclosure avoidance among Black women living with HIV.

Correlates of ART Use Among Newly Diagnosed HIV Positive Adolescent Girls and Young Women Enrolled in HPTN 068

Despite expanded access to HIV treatment worldwide, poor HIV care outcomes persist among adolescent girls and young women (AGYW). This study was conducted among AGYW recruited from the HPTN 068 cohort who had sero-converted to HIV during the main trial between 2011 and 2014. The aim was to examine correlates of anti-retroviral treatment (ART) use. Log binomial regression was used to estimate the crude associations between social support, stigma, and HIV status disclosure and current ART use. Adjusted analyses were also conducted controlling for age and time since diagnosis. Seventy-nine AGYW were included in this analysis. Median age of participants was 20 (range: 17 to 24) and time since diagnosis ranged from 0.5 to 4.8 years (median = 2.1). Over 75% of AGYW (n = 60) had sought HIV care at some point, with the same number reporting previous disclosure of their sero-status. However, just 43% (n = 34) of participants were on treatment at the time of the interview. Over half of participants (n = 44; 55.7%) reported social support was available to them most or all of the time, and the median stigma score was 90 (range 80-113). Adjusted analyses found higher current ART use among those who had disclosed their status (adjusted prevalence ratio (aPR): 3.19; 95% confidence interval (CI) 1.09, 9.32; p = 0.0339) and those with lower scores on the disclosure concern sub-scale of the Berger HIV Stigma Scale (aPR: 0.88; 95% CI 0.79, 0.98; p = 0.0236). ART use among AGYW living with HIV and enrolled in HPTN 068 was low despite relatively high linkage to care during the trial. Interventions aimed at minimizing individuals' concerns about disclosure and improving onward disclosure of one's status could further improve ART utilization among AGYW living with HIV in South Africa.

Low Disclosure Rates to Sexual Partners and Unsafe Sexual Practices of Youth Recently Diagnosed with HIV; Implications for HIV Prevention Interventions in South Africa

The study investigated the motivation to disclose or the decision to withhold one’s HIV serostatus to one’s partners and assessed the implications of non-disclosure on young peoples’ sexual behaviour and access to treatment. This was a cross-sectional survey conducted with 253 youth aged 18–25 years receiving antiretroviral therapy in a health district in North West Province, South Africa. The majority were female (75%), the mean time since the HIV diagnosis was 22 months, 40% did not know their partner’s HIV status, 32% had more than two sexual partners, and 63% had not used a condom during the last sexual act. The prevalence of disclosure was 40%, 36% delayed disclosure for over a year, and most disclosed to protect the partner from HIV transmission, to receive support, and to be honest and truthful. The prevalence of non-disclosure was high, as 60% withheld disclosure due to fear of abandonment, stigma and discrimination, accusations of unfaithfulness, and partner violence. Over half (55%) had no intentions to disclose at all. The lower disclosure rates imply that HIV transmission continues to persist among sexual partners in these settings. The findings suggest that high levels of perceived stigma impact on disclosure and HIV treatment, which increases the risk of on-going HIV transmission among youth receiving long-term antiretroviral therapy (ART) in South Africa.

Structures of Sexuality: Sexual Stigma, Disclosure, and HIV Risk with Primary Female Partners Among Behaviorally Bisexual Black Men

HIV continues to disproportionately impact bisexual Black men, as well as their female partners, in the U.S. There is a need to better understand how stigma and disclosure affect sexual risk for men and their female partners. This article describes the relationship between sexual stigma and HIV risk with primary female partners among a sample of 121 behaviorally bisexual Black men of mixed HIV status in the San Francisco Bay Area. Multivariate analyses tested to see if each of three stigma measures (bisexual stigma, internalized homophobia, difficulty with bisexual identity) would have any effect on participants' condom use. Quantitative analyses found that sexual stigma increased men's sexual risk through inhibiting disclosure of their sexual activity with men to their female partners. Men who reported higher levels of bisexual stigma and internalized homophobia reported that it was harder to disclose having sex with men to their primary female partner, which was significantly related to lower levels of condom use. Stigma reduction HIV prevention interventions are needed that address bisexual stigma experienced by Black men. HIV prevention interventions, including stigma reduction programs, must target both men and women to effectively reduce bisexual stigma and address the structural and relationship contexts of HIV.