Persisting stigma reduces the utilisation of HIV-related care and support services in Viet Nam

Navigating cultural and gender aspects of stigma among women living with HIV in Vietnam

Women living with HIV often face intersecting challenges of stigma and gender inequality. In Vietnam, this issue is potentially exacerbated by the patriarchal culture. From December 2021 to March 2022, we conducted in-depth interviews with 30 women living with HIV in Hanoi to better understand their experiences and the coping mechanisms to navigate HIV stigma, cultural beliefs and gender norms. The interviews explored various topics including women's social and family roles in Vietnam, HIV-related beliefs, stigma and its impact on one's health and coping strategies. Participants reported stereotypes that assumed that women living with HIV had either engaged in sex work or behaved promiscuously. These stereotypes render them vulnerable to judgement and discrimination owing to widespread expectations of female virtue. As a result, women living with HIV often enacted non-disclosure and self-isolation to avoid stigma. This self-stigmatisation negatively impacted their healthcare-seeking, employment opportunities and ability to fulfil traditional family-caring roles. Conversely, many participants exhibited resilience with the support of family and peers. Overall, the complex interplay between gender, culture and HIV stigma underscores the importance of developing culturally appropriate, multifaceted approaches to engaging family and peers, modifying gender-based discriminatory social practices and enhancing women's self-efficacy and empowerment in Vietnam.

Intersectionality of HIV Stigma with Female Identity: An Investigation among Women Living with HIV/AIDS in Vietnam

Women living with HIV/AIDS (WLHA) in Vietnam encounter challenges stemming from HIV-related stigma and gender disparities. This study delves into the intersectionality of HIV-related stigma and gender disparities as perceived by WLHA. A cross-sectional survey was conducted among 91 WLHA in Hanoi, Vietnam. Two sets of identically worded scales were used to measure awareness, agreement, and application of stigma towards people living with HIV/AIDS (PLHA) and WLHA. A larger difference between stigma scores towards WLHA and that of PLHA represents a higher level of female-specific stigma. Univariate analyses and multiple regressions were conducted to identify demographic and psycho-social factors associated with the gendered differences in stigma measures. Multiple linear regression showed that WLHA who were currently married were more likely to apply stigma concepts to themselves due to gender identity (adjusted beta coefficient (aBeta Coef) = 0.223). Psychological capital was negatively associated with awareness of stigma towards female identity (aBeta Coef = -0.261). A higher perceived norm in women's equity and power was associated with less self-application of female-specific stigma (aBeta Coef = -0.294). Our findings underscore the importance of addressing psychological well-being and promoting gender equity norms as essential components in the efforts to reduce female-specific HIV-related stigma in WLHA.

Adapting a health facility HIV stigma-reduction participatory training intervention to address drug use stigma in HIV care and treatment clinics in Dar es Salaam, Tanzania

BACKGROUND

HIV prevalence among people who use drugs (PWUD) in Tanzania is 4-7 times higher than in the general population, underscoring an urgent need to increase HIV testing and treatment among PWUD. Drug use stigma within HIV clinics is a barrier to HIV treatment for PWUD, yet few interventions to address HIV-clinic drug use stigma exist. Guided by the ADAPT-ITT model, we adapted the participatory training curriculum of the evidence-based Health Policy Plus Total Facility Approach to HIV stigma reduction, to address drug use stigma in HIV care and treatment clinics (CTCs).

METHODS

The first step in the training curriculum adaptation process was formative research. We conducted 32 in-depth interviews in Dar es Salaam, Tanzania: 18 (11 men and 7 women) with PWUD living with HIV, and 14 with a mix of clinical [7] and non-clinical [7] CTC staff (5 men and 9 women). Data were analyzed through rapid qualitative analysis to inform initial curriculum adaptation. This initial draft curriculum was then further adapted and refined through multiple iterative steps of review, feedback and revision including a 2-day stakeholder workshop and external expert review.

RESULTS

Four CTC drug use stigma drivers emerged as key to address in the curriculum adaptation: (1) Lack of awareness of the manifestations and consequences of drug use stigma in CTCs (e.g., name calling, ignoring PWUD and denial of care); (2) Negative stereotypes (e.g., all PWUD are thieves, dangerous); (3) Fear of providing services to PWUD, and; (4) Lack of knowledge about drug use as a medical condition and absence of skills to care for PWUD. Five, 2.5-hour participatory training sessions were developed with topics focused on creating awareness of stigma and its consequences, understanding and addressing stereotypes and fears of interacting with PWUD; understanding drug use, addiction, and co-occurring conditions; deepening understanding of drug use stigma and creating empathy, including a panel session with people who had used drugs; and working to create actionable change.

CONCLUSION

Understanding context specific drivers and manifestations of drug use stigma from the perspective of PWUD and health workers allowed for ready adaptation of an existing evidence-based HIV-stigma reduction intervention to address drug use stigma in HIV care and treatment clinics. Future steps include a pilot test of the adapted intervention.

Translation and cultural adaptation of drug use stigma and HIV stigma measures among people who use drugs in Tanzania

INTRODUCTION

People who use drugs (PWUD) experience stigma from multiple sources due to their drug use. HIV seroprevalence for PWUD in Tanzania is estimated to range from 18 to 25%. So, many PWUD will also experience HIV stigma. Both HIV and drug use stigma have negative health and social outcomes, it is therefore important to measure their magnitude and impact. However, no contextually and linguistically adapted measures are available to assess either HIV or drug use stigma among PWUD in Tanzania. In response, we translated and culturally adapted HIV and drug use stigma measures among Tanzanian PWUD and described that process in this study.

METHODS

This was a cross-sectional study. We translated and adapted existing validated stigma measures by following a modified version of Wild's ten steps for translation and adaptation. We also added new items on stigmatizing actions that were not included in the original measures. Following translation and back translation, we conducted 40 cognitive debriefs among 19 PWUD living with and 21 PWUD not living with HIV in Dar es Salaam to assess comprehension of the original and new items. For challenging items, we made adaptations and repeated cognitive debriefs among ten new PWUD participants where half of them were living with HIV.

RESULTS

Most of the original items (42/54, 78%), response options and all items with new 12 stigmatizing actions were understood by participants. Challenges included response options for a few items; translation to Swahili; and differences in participants' interpretation of Swahili words. We made changes to these items and the final versions were understood by PWUD participants.

CONCLUSION

Drug use and HIV stigma measures can successfully be translated and culturally adapted among Tanzanian PWUD living with and without HIV. We are currently conducting research to determine the stigma measures' psychometric properties and we will report the results separately.

Characterization of HIV-Related Stigma in Myanmar

Characterizing HIV-related stigma and its impacts are important for interventions toward their elimination. A cross-sectional study was conducted in 2016 to evaluate enacted and internalized stigma among adult people living with HIV (PLWH) across four cities in Myanmar using the India Stigma Index questionnaire. Multivariable regression analyses were performed to determine differences in measured enacted and internalized stigma outcomes. Among 1,006 participants, 89% reported any stigma indicator, 47% enacted stigma, and 87% internalized stigma. In regression analysis, city and duration of illness were associated with higher enacted stigma, and younger age was associated with higher internalized stigma. Those with HIV duration > 7.4 years had mean enacted stigma nearly 2 units higher than the overall mean. Internalized stigma increased with duration of illness and leveled off at 5 years. PLWH from smaller cities experienced lower stigma. In Myanmar, nearly 90% of PLWH experience stigma, results that reflect a unique transition point.

Assessment of HIV viral load monitoring in remote settings in Vietnam - comparing people who inject drugs to the other patients

INTRODUCTION

Increasing access to viral load (VL) monitoring is essential to fight HIV epidemics. In remote settings in Vietnam, using dried blood spot (DBS) sampling for specimen collection could improve the situation. Here, people who inject drugs (PWID) represent many newly antiretroviral therapy (ART)-initiated patients. The goals of this evaluation were to evaluate if access to VL monitoring and the rate of virological failure differed between PWID and non-PWID.

METHODS

Prospective cohort study of patients newly initiated on ART in remote settings in Vietnam. DBS coverage at 6, 12 and 24 months of ART was investigated. Factors associated with DBS coverage were identified through logistic regression, as were factors associated with virological failure (VL ≥1,000 copies/mL) at 6, 12 and 24 months of ART.

RESULTS

Overall 578 patients were enrolled in the cohort, of whom 261 (45%) were PWID. DBS coverage improved from 74.7% to 82.9% between 6 and 24 months of ART (p = 0.001). PWID status was not associated with DBS coverage (p = 0.74), but DBS coverage was lower in patients who were late to clinical visits and in those in WHO stage 4 (p = 0.023 and p = 0.001, respectively). The virological failure rate decreased from 15.8% to 6.6% between 6 and 24 months of ART (p<0.001). In multivariate analysis, PWID were more at risk of failure (p = 0.001), as were patients who were late to clinical visits (p<0.001) and not fully adherent (p<0.001).

CONCLUSIONS

Despite training and simple procedures, DBS coverage was not perfect. DBS coverage was not associated with PWID status. Close management is required for effective routine HIV VL monitoring. PWID were more at risk of failure, as were patients who were not fully adherent and patients who were late to clinical visits. Specific interventions targeting these patients are needed to improve their outcomes. Overall, efforts in coordination and communication are essential to improve global HIV care.

TRIAL REGISTRATION

Clinical Trial Number: NCT03249493.

Stigma experienced by people living with HIV who are on methadone maintenance treatment and have symptoms of common mental disorders in Hanoi, Vietnam: a qualitative study

BACKGROUND

Stigma around human immunodeficiency virus (HIV), injection drug use (IDU), and mental health disorders can be co-occurring and have different impacts on the well-being of people living with HIV (PWH) who use drugs and have mental health disorders. This stigma can come from society, health professionals, and internalized stigma. A person who has more than one health condition can experience overlapping health-related stigma and levels of stigma which can prevent them from receiving necessary support and healthcare, serving to intensify their experience with stigma. This study investigates HIV, drug use, and mental health stigmas in three dimensions (social, internalized, and professional) around PWH on methadone maintenance treatment (MMT) who have common mental disorders (CMDs) including depression, anxiety, and stress-related disorders in Hanoi, Vietnam.Please check and confirm whether corresponding author's email id is correctly identified.The cooresponding author's email is correct METHODS: We conducted semi-structured, in-depth interviews (IDIs) (n = 21) and two focus group discussions (FGDs) (n = 10) with PWH receiving MMT who have CMD symptoms, their family members, clinic health care providers, and clinic directors. We applied thematic analysis using NVIVO software version 12.0, with themes based on IDI and FGD guides and emergent themes from interview transcripts.

RESULTS

The study found evidence of different stigmas towards HIV, IDU, and CMDs from the community, family, health care providers, and participants themselves. Community and family members were physically and emotionally distant from patients due to societal stigma around illicit drug use and fears of acquiring HIV. Participants often conflated stigmas around drug use and HIV, referring to these stigmas interchangeably. The internalized stigma around having HIV and injecting drugs made PWH on MMT hesitant to seek support for CMDs. These stigmas compounded to negatively impact participants' health.

CONCLUSIONS

Strategies to reduce stigma affecting PWH on MMT should concurrently address stigmas around HIV, drug addiction, and mental health. Future studies could explore approaches to address internalized stigma to improve self-esteem, mental health, and capacities to cope with stigma for PWH on MMT.

TRIAL REGISTRATION

NCT04790201, available at clinicaltrials.gov.

Measuring and Addressing Stigma Within HIV Interventions for People Who Use Drugs: a Scoping Review of Recent Research

PURPOSE OF REVIEW

Persistent stigma remains a crucial barrier to HIV prevention and treatment services among people who use drugs (PWUD), particularly for those living with or at-risk for HIV. This scoping review examines the current state of science with regard to approaches for measuring and addressing stigma within HIV interventions among PWUD.

RECENT FINDINGS

Sixteen studies fit the inclusion criteria for this review. Half the studies originated within the USA, and the remaining represented four different regions. Within these studies, stigma was measured using various quantitative, qualitative, and mixed methods. The studies primarily focused on HIV stigma, including value-based judgments, anticipated stigma, and perceived stigma domains. Information-based and skills building approaches at the individual level were the most common for the stigma reduction interventions. Adoption of systematic evaluations is needed for measuring stigma, including intersectional stigma, within HIV interventions among PWUD. Future studies should focus on developing multilevel intersectional stigma reduction interventions for PWUD with and at-risk for HIV globally.

Drug use stigma, antiretroviral therapy use, and HIV viral suppression in a community-based sample of people with HIV who inject drugs

OBJECTIVE

To examine the association of drug use stigma with antiretroviral therapy (ART) use and HIV viral suppression among people with HIV who inject drugs in India.

DESIGN

Cross-sectional biobehavioral survey.

METHODS

Between August 2016 and May 2017, persons aged at least 18 years who reported injection drug use in the past 2 years were recruited via respondent-driven sampling (RDS) in 12 Indian cities (approximately 1000 per city). The analysis was restricted to participants with laboratory-confirmed HIV infection who self-reported a prior HIV diagnosis and were eligible for ART per concurrent national HIV treatment guidelines. Enacted and internalized drug use stigma were each measured by five to six-item subscales. The study outcomes were HIV viral suppression (<150 copies/ml) and self-reported past 30-day ART use. RDS-II weighted multivariable logistic regression with a city-level random-intercept was used to estimate adjusted odds ratios (aOR) and corresponding 95% confidence intervals (CIs).

RESULTS

Among 971 ART-eligible participants previously diagnosed with HIV, 65.1% reported ART use and 56.1% were virally suppressed. Reporting any enacted stigma (vs. none) was associated with lower odds of ART use [aOR = 0.26 (95% CI = 0.15-0.44)] and viral suppression [aOR = 0.49 (95% CI = 0.31-0.78)]. High internalized stigma scores (>median vs. ≤median) were associated with lower odds of viral suppression among participants aged at least 35 years [aOR = 0.51 (95% CI = 0.27-0.97)] but not among participants aged less than 35 years [aOR = 1.22 (95% CI = 0.57-2.60)]. Similar associations were observed in analyses restricted to participants ever linked to HIV care.

CONCLUSION

Drug use stigma may be a barrier to HIV viral suppression among people with HIV who inject drugs, thereby hindering efforts to achieve HIV control.

A pretest-posttest design to assess the effectiveness of an intervention to reduce HIV-related stigma and discrimination in healthcare settings in Vietnam

Introduction

Stigma and discrimination are important barriers to HIV epidemic control. We implemented a multi‐pronged facility‐level intervention to reduce stigma and discrimination at health facilities across three high‐burden provinces. Key components of the intervention included measurement of stigma, data review and use, participatory training of healthcare workers (HCWs), and engagement of people living with HIV and key populations in all stigma reduction activities.

Methods

From July 2018 to July 2019, we assessed HIV‐related stigma and discrimination among patients and HCWs at 10 facilities at baseline and 9 months following an intervention. A repeated measures design was used to assess the change in stigma and discrimination among HCWs and a repeated cross‐sectional design assessed the change in stigma and discrimination experienced by PLHIV. HCWs at target facilities were invited at random and PLHIV were recruited when presenting for care during the two assessment periods. McNemar's test was used to compare paired proportions among HCWs, and chi‐square test was used to compare proportions among PLHIV. Mixed models were used to compare outcomes before and after the intervention.

Results

Semi‐structured interviews were conducted with 649 and 652 PLHIV prior to and following the intervention, respectively. At baseline, over the previous 12 months, 21% reported experiencing discrimination, 16% reported self‐stigma, 14% reported HIV disclosure without consent and 7% had received discriminatory reproductive health advice. Nine months after the intervention, there was a decrease in reported stigma and discrimination across all domains to 15%, 11%, 7% and 3.5%, respectively (all p‐values <0.05). Among HCWs, 672 completed the pre‐ and post‐intervention assessment. At baseline, 81% reported fear of HIV infection, 69% reported using unnecessary precautions when caring for PLHIV, 44% reported having observed other staff discriminate against PLHIV, 54% reported negative attitudes towards PLHIV and 41% felt uncomfortable working with colleagues living with HIV. The proportions decreased after the intervention to 52%, 34%, 32%, 35% and 24%, respectively (all p‐values <0.05).

Conclusions

A multi‐pronged facility‐level intervention was successful at reducing healthcare‐associated HIV‐related stigma in Vietnam. The findings support the scale‐up of this intervention in Vietnam and highlight key components potentially applicable in other settings.

How Anti-Substance Abuse Campaigns Influence Substance Abusers' Psychological Health in Chinese Communities: The Mediating Role of Perceived Stigma

The current study explored how anti-substance abuse campaigns influence substance abusers' psychological health through the perception of stigma. The study is based on a sample of substance abusers who received community-based treatments (n = 3457) and used structural equation modeling to estimate the role of perceived stigma in mediating between perceptions of overstatement of harm conveyed in anti-substance abuse campaigns and psychological outcomes. The results revealed that substance abusers' perception of overstatement of the harm caused by the substances and substance abusers enhanced their perceived stigma and impaired their psychological health in terms of anxiety, depression, and somatization, through both direct and indirect pathways. The results advocate for proper strategies in the design of anti-substance abuse campaigns. Possible initiatives to reduce substance abusers' perceived stigma are recommended.

HIV-related stigma, symptoms of depression and their association with suicidal ideation among people living with HIV in Ho Chi Minh City, Vietnam

To date, little are known about HIV-related stigma, symptoms of depression (SOD) and suicidal ideation among people living with HIV (PLHIV) in Vietnam. This study aimed to estimate the level of stigma, SOD and suicidal ideation and to explore the direction and magnitude of the relationship between stigma, SOD and suicidal ideation among Vietnamese PLHIV. A cross-sectional study was conducted in four outpatient clinics providing healthcare services including antiretroviral therapy (ART) for PLHIV in Ho Chi Minh City. At each clinic, patients were chosen using the systematic sampling technique. Participants underwent face-to-face interviews through a pre-defined structural questionnaire that included validated scales. Among 777 PLHIV in the analysis, most were male (81.1%) and the average age was 34.3 (SD = 8.8) years. Two-thirds of PLHIV had a moderate-to-high level of HIV stigma. Symptoms of depression were identified in 41.4% of PLHIV. Suicidal ideation was reported by 26.3% of PLHIV. Based on univariate and multivariate logistic regression, higher levels of SOD and HIV stigma were positively associated with suicidal ideation. For PLHIV with extreme stigma and SOD, the probability of having suicidal ideation was up to 80%. The prevalence and association found in this study indicates that interventions for SOD and stigma not only help reduce these two problems but also help address and minimize suicidal ideation in this vulnerable population. In Vietnam, to optimize such interventions, the involvement of families and communities is crucial.

HIV-related perceived stigma and associated factors among patients with HIV, Dilla, Ethiopia: A cross-sectional study

Introduction

Understanding HIV-related perceived stigma has importance in improving the quality of patients and provides a better tackling of HIV stigma. Therefore; the study aimed to assess the prevalence and associated factors of perceived stigma among Patients with HIV attending the clinic at Dilla University Referral Hospital in Ethiopia 2019.

Method

In this Institution based cross-sectional study, a 10-item perceived HIV stigma scale was used to assess HIV-related perceived stigma. Oslo social support scale was used to assess social support related factors. Bivariate and multivariate binary logistic analysis was done to identify associated factors to HIV-related perceived stigma.

Results

The prevalence of HIV-related perceived stigma by using perceived HIV stigma scale among patients with living HIV was 42.7%. Patients who are age groups 25-30 years (AOR = 2.8, 95% CI: 5.72-11.5), age groups 31-39 years (AOR = 1.11, 95% CI: 1.26,4.65), Females (AOR = 2.4, 95% CI: 1.28-4.33), divorced marital status (AOR = 8.9, 95% CI: 3.52-10.61), widowed marital status (AOR = 3.0, 95% CI: 2.74-7.60), Primary educational status (AOR = 7.5,95% CI: 3.45-9.74) and Study participants those who use alcohol (AOR = 1.0 95% CI: 1.57-2.11) were more likely to have HIV-related perceived stigma.

Conclusion

This calls a holistic approach to the prevention and intervention of HIV-related perceived stigma. Emphasis should also be given for HIV-related perceived stigma.

Registration

This study was registered research registry with the registration number (researchregistry7112).

Assessing depressive symptoms among people living with HIV in Yangon city, Myanmar: Does being a member of self-help group matter?

Background

While self-help groups have been formed among people living with HIV, few studies have been conducted to assess the role of self-help groups in mitigating depressive symptoms. This study investigated the association between self-help group membership and depressive symptoms among people living with HIV in Yangon, Myanmar.

Methods

In this cross-sectional study, data were collected from people living with HIV at three antiretroviral therapy clinics in 2017. Multiple logistic regression analyses were carried out to examine the associations between having self-help group membership and depressive symptoms. Three ART clinics were purposively selected based on the recommendation from the National AIDS Program in Myanmar. At these clinics, people living with HIV were recruited by a convenience sampling method.

Results

Among people living with HIV recruited in this study (n = 464), 201 (43.3%) were members of a self-help group. The membership was not associated with having depressive symptoms (adjusted odds ratio [AOR] 1.59, 95% confidence interval [CI] 0.98–2.59). Factors associated with having depressive symptoms were female (AOR 3.70, 95% CI 1.54–8.88) and lack of social support (AOR 0.97, 95% CI 0.96–0.98) among self-help group members, and female (AOR 3.47, 95% CI 1.70–7.09), lack of social support (AOR 0.98, 95% CI 0.97–0.99), and internalized stigma (AOR 1.28, 95% 1.08–1.53) among non-members.

Conclusions

This study did not find evidence on the association between membership in self-help groups and depressive symptoms among people living with HIV. Social support was a protective factor against depressive symptoms both self-help group members and non-members, although the level of social support was lower among members than non-members. The activities of self-help groups and care provided by the ART clinics should be strengthened to address mental health problems among people living with HIV in the study site.

HIV- and Drug Use-Related Stigma and Service Provision Among Community Health Workers in Vietnam

This study compared community health workers' (CHW) stigma towards people living with HIV (PLH) and people who use drugs (PWUD) and explored the relationship between stigma and CHWs' confidence level in providing HIV/drug-related services. Using two sets of identically worded questions, levels of stigma towards PWUD and PLH were measured among 120 CHW from 60 communes in Vietnam. The associations between CHWs' confidence in service provision and stigma towards PWUD and PLH were examined using a linear mixed-effects regression model. The majority of the CHW reported higher levels of stigma towards PWUD than towards PLH. Compared to the CHW reporting higher stigma towards PWUD, those with higher stigma towards PLH were significantly less confident in service provision. Social opprobrium attached to drug-using behaviors can be a major driver behind the overall HIV stigma. CHWs' fear of HIV infection should be tackled to boost their confidence in HIV/drug-related care provision.

The patient voice: a survey of worries and anxieties during health system transition in HIV services in Vietnam

Background

Vietnam is shifting toward integrating HIV services into the public health system using social health insurance (SHI), and the HIV service delivery system is becoming decentralized. The study aim was to investigate current SHI coverage and patients’ perspectives on this transition.

Methods

A survey of 1348 HIV-positive patients on antiretroviral therapy (aged ≥18 years) was conducted at an HIV outpatient clinic at a central-level hospital in Hanoi, Vietnam, in October and November 2018. Insurance coverage, reasons for not having a SHI card, perceived concerns about receiving HIV services in SHI-registered local health facilities, and willingness to continue regularly visiting the current hospital were self-reported. Logistic regression analyses were performed to analyze factors associated with not having a SHI card and having concerns about receiving HIV services in SHI-registered hospitals/clinics.

Results

SHI coverage was 78.0%. The most frequently reported reason for not having a SHI card was that obtaining one was burdensome, followed by lack of information on how to obtain a card, and financial problems. Most patients (86.6%) had concerns about receiving HIV services at SHI-registered local health facilities, and disclosure of HIV status to neighbors and low quality of HIV services were the main concerns reported. Participants aged < 40 years old and unmarried were more likely to report lack of SHI cards, and women and those aged ≥40 years were more likely to have concerns. However, 91.4% of patients showed willingness to continue regular visits to the current hospital.

Conclusions

Although SHI coverage has been rapidly improving among HIV patients, most participants had concerns about the current system transition in Vietnam. In response to their voiced concerns, strengthening the link between higher-level and lower-level facilities may help to ensure good quality HIV services at all levels while mitigating patients’ worries and anxieties.

The Discrimination Against, Health Status and Wellness of People Who Use Drugs in Italian Services: A Survey

Background and Objectives: The aims of this study are to: describe the sociodemographic characteristics and typology of drug addiction among people who use drugs that attend the Servizio per le Dipendenze (SerD), and evaluate the competence and ability of these rehabilitation services to improve their health status and wellness. Materials and Methods: A cross-sectional study was conducted from January to July 2017. Patients attending two selected SerD facilities in the city of Naples, Italy were interviewed with a questionnaire gathering information on sociodemographic data, characteristics of drug addiction, characteristics of enrolment at the SerD, self-reported health status and wellness, and reports of the discrimination suffered. Results: Among the 451 people interviewed, 72.3% had started taking drugs by the age of 20, and half of them have used drugs within the last year. 54.5% of responders attended SerD for more than 10 years, and the two main reasons for attendance were to get help and to get methadone. 79.4% were declared to have a good/very good/excellent health status at the time of interviewing. 53.7% reported suffering from discrimination. Conclusions: Based on our study, discrimination is higher in participants who attended SerD for more than one year, who were formerly in prison, or who were current drug users.

Changing Sources of Stigma against Patients with HIV/AIDS in the Rapid Expansion of Antiretroviral Treatment Services in Vietnam

Stigmatization against HIV/AIDS greatly hinders efforts to increase the accessibility and utilization of HIV/AIDS services to meet the 90-90-90 goal. This study assessed the stigmatization and discrimination experienced by people living with HIV (PLWH) across multiple social settings such as family, community, and healthcare facilities in Vietnam. A total of 1,016 patients (63.8% males, mean age = 35.4) participated in a cross-sectional study using a culturally tailored HIV stigma measure in three HIV-epidemic-concentrated cities in Vietnam. Zero-inflated Poisson models were used to examine factors associated with the number of types of stigma that patients experienced. 86.2% PLWH reported experiencing stigma against HIV/AIDS, more frequently from their community (62.8%) and family (30.2%) than from health care facilities (8%). The level of stigma from community reported by PLWH is associated with socioeconomic status (e.g., income, occupation). The poor and middle economic classes and unemployed patients reported more stigmatization and discrimination from the community. Across all settings, PLWH experienced fewer stigmatization over the course of ART indicating the benefits of rapidly expanded ART programs. PLWH reported more stigmatization and discrimination at the provincial level of the health administration. Those with the history of drug injection reported significantly less stigmatization from healthcare setting. More culturally tailored interventions to reduce stigmatization overall to improve the quality of life and health outcomes of PLWH should be warranted to achieve the 90-90-90 goal. Improving HIV-related knowledge of the general population and providing opportunities for PLWH to be reintegrated into should be considered. Using mass media with positive messages and images would also foster positive attitudes towards HIV/AIDS among the population and could potentially change social values. Continuous training of health staffs' attitude could minimize the occurrence of stigmatization and discrimination at healthcare facilities.

Stigma against patients with HIV/AIDS in the rapid expansion of antiretroviral treatment in large drug injection-driven HIV epidemics of Vietnam

Background

Despite existing efforts to provide antiretroviral treatment (ART) for all HIV-diagnosed people, stigma deprives them of the highest attainable health status and challenges the effectiveness of ART program in Vietnam. This study aimed to assess five dimensions of HIV-related stigma and explore its associated factors among ART patients in a multisite survey. Implications of this study support the development of HIV policies to improve patients’ access, utilization, and outcomes of ART program toward the 90-90-90 goal in Vietnam.

Methods

A total of 1133 ART patients who were recruited by convenience sampling method from 8 ART clinics in Hanoi and Nam Dinh in a cross-sectional study from January to August 2013. Multivariate logistic regression was employed to identify factors associated with stigmatization.

Results

The majority of participants reported experiencing stigmatization due to shame (36.9%), blame/judge (21.6%), and discrimination (23.4%). Further, 91.5% of participants disclosed their HIV status with others. The likelihood of experiencing stigmatization did not only associate with the patients’ socioeconomic status (e.g., age, occupation, education) and HIV status disclosure, but also their health problems. Those with anxiety or depression and perceived lower quality of life were more likely to experience stigma.

Conclusions

To maximize the efficiency of the ART program, it is essential to develop interventions that reduce stigma involving individuals, families, and communities, and recognize and address complex health problems especially those patients showing depressive symptoms. Increasing quality of life of HIV-positive patients by providing vocational training, financial, family, and peer support will reduce the likelihood of experiencing stigma.

HIV Positive Patients' Experience of Receiving Health Care Services: A Phenomenology Study in Iran

Introduction:

Most of the studies on HIV/AIDS health care status are usually conducted in big cities while small towns and rural areas are faced with specific challenges. This study aimed to identify the barriers and problems encountered by HIV-positive patients when receiving health services in the small cities and rural areas of Iran.

Methodology:

This is a qualitative study that was conducted using an interpretive phenomenology method in 2016. This study was conducted through a semi-structured interview for which a purposeful sampling method was used. In the present study, data saturation was observed after 15 interviews, but more than 17 interviews were conducted to ensure the reliability of the interview. Data were analyzed by Colaizzi's method using MAXQDA10 software.

Findings:

Barriers and problems encountered by patients when receiving health care services consisted of 10 categories, 32 main themes and 67 sub-themes. The categories were as follows: fear of revealing the disease, fear of confronting providers, seeking support, not visiting health care providers, inappropriate behavior of health care staff, concealing the disease, hardship endurance, financial concerns, psychological stress and pressure, and disclosure of patient information.

Conclusion:

Recognizing the problems of HIV-positive patients in using health care services and resolving them can help to reassure the patients about the health system. Introduction of supporting policies and regulations, appropriate public education, training health sector personnel, and provision of medical equipment and facilities would positively affect the process of solving the problems of HIV-Patients (treating HIV patients).

"Who has ever loved a drug addict? It's a lie. They think a 'teja' is as bad person": multiple stigmas faced by women who inject drugs in coastal Kenya

BACKGROUND

A tenth of all people who inject drugs in Kenya are women, yet their social contexts and experiences remain poorly understood. This paper reports how multiple forms of stigma are experienced by women who inject drugs in coastal Kenya and the impact that they have on their ability to access essential health services.

METHODS

In 2015, in-depth interviews and focus group discussions were held with 45 women who inject drugs in two coastal towns. These data were supplemented with in-depth interviews with five individual stakeholders involved in service provision to this population. Data were analyzed thematically using NVivo.

RESULTS

Women who inject drugs experience multiple stigmas, often simultaneously. These included the external stigma and self-stigma of injection drug use, external gender-related stigma of being a female injecting drug user, and the external stigma of being HIV positive (i.e., among those living with HIV). Stigma led to rejection, social exclusion, low self-esteem, and delay or denial of services at health facilities.

CONCLUSION

HIV and harm reduction programs should incorporate interventions that address different forms of stigma among women who inject drugs in coastal Kenya. Addressing stigma will require a combination of individual, social, and structural interventions, such as collective empowerment of injecting drug users, training of healthcare providers on issues and needs of women who inject drugs, peer accompaniment to health facilities, addressing wider social determinants of stigma and discrimination, and expansion of harm reduction interventions to change perceptions of communities towards women who inject drugs.

Social Support as a Key Protective Factor against Depression in HIV-Infected Patients: Report from large HIV clinics in Hanoi, Vietnam

Depression is the most common mental health issue among people living with HIV/AIDS (PLWHA). This study explored how different types and sources of social support are associated with depression among HIV-infected patients in Vietnam. We carried out a cross-sectional survey on 1,503 HIV-infected patients receiving antiretroviral therapy at two HIV clinics in Hanoi in 2016. Depression was prevalent in 26.2% of participants. Higher score of social support, especially emotional/informational support and positive social interaction, showed significant association with lower depression rate. Although family was primary source of all types of social support, receiving emotional/informational support not only from family but also from outside of family correlated with a lower proportion of depression. In countries with constrained social resources and/or with family-oriented social structures, as in Vietnam, expanding social networks between HIV populations and society is a potentially important option for reducing depression.

Barriers to access and uptake of antiretroviral therapy among HIV-positive men who have sex with men in Hanoi, Vietnam: from HIV testing to treatment

Little is known about the experiences of Vietnamese men who have sex with men in accessing HIV testing and treatment. We aimed to explore barriers to access and uptake of antiretroviral therapy (ART) among HIV-positive men who have sex with men in Hanoi. During 2015, we conducted qualitative interviews with 35 participants recruited using snowball sampling based on previous research and social networks. Key individual impediments to ART uptake included inadequate preparation for a positive diagnosis and the dual stigmatisation of homosexuality and HIV and its consequences, leading to fear of disclosure of HIV status. Health system barriers included lack of clarity and consistency about how to register for and access ART, failure to protect patient confidentiality and a reticence by providers to discuss sexual identity and same-sex issues. Results suggest fundamental problems in the way HIV testing is currently delivered in Hanoi, including a lack of client-centred counselling, peer support and clear referral pathways. Overcoming these barriers will require educating men who have sex with men about the benefits of routine testing, improving access to quality diagnostic services and building a safe, confidential treatment environment for HIV-positive men to access, receive and remain in care.

Drug-related stigma and access to care among people who inject drugs in Vietnam

INTRODUCTION AND AIMS

There are considerable challenges faced by people with a history of injecting drug use (PWID) in Vietnam, including drug-related stigma and lack of access to healthcare. Seeking and utilising healthcare, as well as harm reduction programs for PWID, are often hampered by drug-related stigma. This study aimed to examine the impacts of drug-related stigma on access to care and utilisation of harm reduction programs among PWID in Vietnam.

DESIGN AND METHODS

A cross-sectional study was conducted in two provinces in Vietnam, Phú Thọ and Vinh Phúc. The study participants completed the survey by using Audio Computer-Assisted Self-Interview between late 2014 and early 2015. Linear multiple regression models and logistic regression models were used to assess the relationship among drug-related stigma, access to care and utilisation of harm reduction programs, including methadone maintenance treatment (MMT) and needle exchange programs (NEP).

RESULTS

A total of 900 PWID participated in this study. Drug-related stigma was significantly associated with lower level of access to care, but not with utilisation of MMT or NEP. Older age was positively associated with higher levels of access to care. Levels of education were positively correlated with access to care, as well as utilisation of MMT and NEP.

DISCUSSION AND CONCLUSIONS

This study underscores the need for future interventions to reduce drug-related stigma in society and in health-care settings to improve PWID's utilisation of care services. Special attention should be paid to younger PWID and those with lower levels of education.

Stigmatization among methadone maintenance treatment patients in mountainous areas in northern Vietnam

Background

Stigma and discrimination may adversely affect the benefits of methadone maintenance treatment (MMT) for drug users, especially in disadvantaged settings. This study assessed stigma and discrimination against MMT patients in the mountainous and rural areas in Vietnam and explored their associated factors to inform implementation strategies.

Methods

We interviewed 241 MMT patients in two clinics: one in Tuyen Quang Province’s inner city and the other in Son Duong District, to assess stigma and discrimination that patients perceived and experienced. Socioeconomic status, health behaviors, health status, and history of drug abuse were examined. Multivariate linear and logistic regression models were used to explore factors associated with stigma and discrimination.

Results

The majority of respondents reported experiencing stigma and discrimination including blame/judgment (95.1%), shame (95.1%), disclosure (71.4%), and the fear of human immunodeficiency virus (HIV) transmission by others (74.1%). Unemployed patients were more likely to experience discrimination (Coef = −1.18, 95% CI = −1.87; −0.89). Those who were taking an antiretroviral were more likely to disclose their health status (Coef = 2.27, 95% CI = 0.6; 3.94). In addition, a higher likelihood of being blamed/judged and shamed was associated with those who suffered from anxiety/depression (Coef = 1.59, 95% CI = 0.24; 2.93 and Coef = 1.07, 95% CI = 0.36; 1.79, respectively).

Conclusions

MMT patients in these mountainous areas perceived high levels of stigma and discrimination which were associated with mental health disorders, unemployment, and HIV infection. These findings highlighted the importance of reducing drug use and HIV-related stigma against high-risk populations. Besides, psychosocial and familial supports, as well as job referrals, also play crucial roles in terms of promoting quality of life among MMT patients.

Healthcare avoidance by people who inject drugs in Bangkok, Thailand

BACKGROUND

Although people who inject drugs (IDU) often contend with various health-related harms, timely access to health care among this population remains low. We sought to identify specific individual, social and structural factors constraining healthcare access among IDU in Bangkok, Thailand.

METHODS

Data were derived from a community-recruited sample of IDU participating in the Mitsampan Community Research Project between July and October 2011. We assessed the prevalence and correlates of healthcare avoidance due to one's drug use using multivariate logistic regression.

RESULTS

Among 437 participants, 112 (25.6%) reported avoiding health care because they were IDU. In multivariate analyses, factors independently associated with avoiding health care included having ever been drug tested by police [adjusted odds ratio (AOR) = 1.80], experienced verbal abuse (AOR = 3.15), been discouraged from engaging in usual family activities (AOR = 3.27), been refused medical care (AOR = 10.90), experienced any barriers to health care (AOR = 4.87) and received healthcare information and support at a drop-in centre (AOR = 1.92) (all P < 0.05).

CONCLUSIONS

These findings highlight the need to address the broader policy environment, which perpetuates the criminalization and stigmatization of IDU, and to expand peer-based interventions to facilitate access to health care for IDU in this setting.

The Effect of a Multi-Level Intervention on the Initiation of Antiretroviral Therapy (ART) among HIV-Infected Men Who Inject Drugs and Were Diagnosed Late in Thai Nguyen, Vietnam

BACKGROUND

In Vietnam, an estimated 256,000 people are living with HIV, and 58% of HIV-infections reported are among people who inject drugs (PWID). While antiretroviral therapy (ART) is widely available in Vietnam, marginalized hard-to-reach male PWID, demonstrate significantly reduced and delayed access to ART.

METHODS

We investigated the effect of a randomized four-arm multi-level intervention trial on ART initiation among male PWID. Our analysis was conducted among a subset of trial participants (n = 136), who were newly diagnosed as HIV-infected, treatment naïve, and eligible for ART (baseline late diagnosis). The trial arms included: 1, standard of care (HIV testing and counseling); 2, structural-level intervention (door-to-door communications and community video screenings); 3, individual-level intervention (counseling plus group support); and 4, individual-level plus structural-level intervention. In a time-to-event analysis, we used a non-parametric approach for competing risks to estimate cumulative incidence function (CIF) for ART initiation (event of interest) by arm and the difference in CIF for each trial arm as compared to Arm 1. Follow-up was conducted at 6, 12, 18 and 24 months. Data collection occurred from 2009 to 2013.

FINDINGS

By 24-months, 61.0% initiated ART, and 30.9% had died prior to ART initiation. In the first 6 months, participants in arm 4 (individual plus community intervention) had a 28% (95% confidence interval (CI): 6-50%) increased probability of initiating ART. Despite increasing coverage of ART in all arms throughout follow-up, participants in arm 4 retained a 31% (95% CI: 5-56%) increased probability of initiating ART. The individual and community components of the intervention were only effective when delivered together.

CONCLUSIONS

Marginalized, hard-to-reach men, who do not routinely engage in HIV services, and therefore come into care late, may benefit significantly from both individual counseling and group support, in combination with community-focused stigma reduction, when being referred and attempting to initiate urgently needed ART.

Factors associated with HIV viral load suppression on antiretroviral therapy in Vietnam

BACKGROUND

Limited data are available on HIV viral suppression rates among men and women on antiretroviral therapy (ART) and factors associated with HIV RNA viral load (VL) suppression in Vietnam.

METHODS

We conducted a cross-sectional survey of 1255 adult patients on ART for at least 1 year across four provinces in Vietnam. Data collection included a standardised questionnaire, routine laboratory testing, and an HIV VL assay. Bivariate and logistic multivariate analyses were conducted to assess viral suppression rates and factors associated with unsuppressed HIV VL.

RESULTS

The median age was 34.5 years and the median time on ART was 46 months. Gender was 66% male (n=828) and 34% female (n=427). HIV viral suppression below 1000 copies/mL was 93%. Viral suppression among woman was not significantly different than among men (93.7% vs 92.9%; P=0.59). On multivariate analysis, unsuppressed HIV VL was independently associated with lower CD4 cell count, social isolation, high stigma, not receiving a single-tablet daily regimen, multiple late appointments in past year, and immunological failure.

CONCLUSION

On-treatment viral load suppression rates in Vietnam are high and already exceed the UNAIDS 90% target for viral suppression on ART. Gender does not impact viral suppression rates of patients on ART in Vietnam. Access to routine viral load testing should be improved, adherence monitoring and counselling streamlined, and ART regimens simplified to maintain viral suppression rates, as more people start ART. Psychological and social factors are also associated with unsuppressed HIV VL, necessitating treatment support interventions to address social isolation and stigma among people living with HIV in Vietnam.

Drug addiction stigma in relation to methadone maintenance treatment by different service delivery models in Vietnam

Background

The rapid expansion of methadone maintenance treatment (MMT) services has significantly improved health status and quality of life of patients. However, little is known about its impacts on addiction-related stigma and associated factors.

Methods

A cross-sectional survey was conducted in 2013 in Vietnam’s capital, Hanoi, and Nam Dinh province among 1016 methadone maintenance patients; 26.6 % at provincial AIDS centers (PAC) and 73.4 % at district health centers (DHC), respectively. Drug addiction history and related stigma, health status, MMT-related covariates, and sociodemographic characteristics were interviewed.

Results

More than one-sixth of the sample reported experiencing felt or enacted stigma, including Blame or Judgement (17.2 %), Shame (19.9 %), or Others’ fear of HIV transmission (17.1 %). These proportions were higher in PACs than in DHCs, which are integrated with other HIV or general health care services. Very few patients reported being discriminated at the workplace (2.5 %) or at health care services (1.7 %); however, 15.6 % of patients at PACs and 10.6 % of patients at DHCs reported discrimination in their communities. Drug users taking MMT for longer periods were less likely to report felt stigma. Other factors associated with stigma against MMT patients included the lack of comprehensive services, higher education, presence of pain/discomfort, and anxiety/depression, self-reported HIV positive, and number of previous drug rehabilitation episodes.

Conclusion

The study shows a high level of stigma against MMT patients and emphasizes the necessity to integrate MMT with comprehensive health and support services. Mass communication campaigns to reduce stigma against people with drug addiction and HIV/AIDS, as well as vocational trainings and jobs referrals for MMT patients, are needed to maximize the benefits of MMT programs in Vietnam.

Quality of Care and Service Expansion for HIV Care and Treatment

The last two decades have seen exceptional development of antiretroviral treatment programs throughout the world. Over 14 million persons are accessing antiretroviral treatment (ART) treatment as of early 2015, and life expectancy has risen markedly in the most-affected populations. However, large patient numbers threaten to overwhelm already over-burdened health care systems and retention in care remains suboptimal. Developing innovative strategies to alleviate these burdens and retain patients in care remains a challenge. Furthermore, despite this expansion, large populations of HIV-infected persons remain undiagnosed and are unwilling or unable to access care and treatment programs. Marginalized and high-risk populations are particularly in danger of remaining outside of care and are also disproportionately affected by HIV. To reverse the trend and "fast track" our way out of the epidemic, ambitious treatment targets are required, and a concerted effort has to be made to engage these populations into care, initiate ART, and attain viral suppression.

High Treatment Retention Rate in HIV-Infected Patients Receiving Antiretroviral Therapy at Two Large HIV Clinics in Hanoi, Vietnam

Background

Loss to follow-up (LTFU) is viewed as a major challenge in improving retention in HIV treatment. In Vietnam, the reasons for disengagement from clinics and the effect of injection drug use (IDU) on LTFU with unknown outcome (true LTFU) are not well known.

Methods

Patients receiving antiretroviral therapy (ART) from two HIV clinics in Hanoi were included in this observational study between 2007 and 2012, and followed up every 6 months until the end of 2013. The reasons for disengagement from the clinic, and ART status during imprisonment were investigated in patients with a history of IDU to identify true LTFU. The retention rate at 6–54 months and true LTFU rate were calculated. Cox proportional hazards regression models were performed to identify factors associated with true LTFU.

Results

There were 1,431 patients, with a follow-up time of 4,371 person-years (median 2.49 years). At the end of the follow-up period, 71 (5.0%) patients died, 79 (5.5%) transferred to other clinics, 16 (1.1%) disengaged from the clinics, and the calculated true LTFU was 45 (3.1%), with 12-month ART retention rate of 95.3% for the entire study population. Imprisonment was the most frequent reason for disengagement from the clinics. True LTFU correlated significantly with low CD4 count and high plasma viral load, but not history of IDU.

Conclusion

Imprisonment is a major cause of disengagement from HIV care among patients with a history of IDU.

Is Involvement in Sex Work Associated with Engagement in HIV-Related Medical Care in Latin American Men Who Have Sex with Men? Results of a Large, Multinational Internet Survey

Men who have sex with men (MSM) who engage in transactional sex are at increased HIV risk, and face complex barriers to care seeking. Among 2,035 men recruited through an MSM social/sexual networking website in Latin America and who reported being HIV-infected, 186 (9.1%) reported being paid for sex with another man in the past year. Engagement in transactional sex was associated with decreased odds of receiving medical care for HIV (AOR=0.57, 95% CI=0.37-0.85). No significant differences were seen in being on antiretroviral therapy (ART) or ART adherence once in care. Interventions in this population should focus on reducing barriers to engagement in care.

Antiretroviral treatment coverage for men who have sex with men and female sex workers living with HIV in Cameroon

BACKGROUND

Men who have sex with men (MSM) and female sex workers (FSW) are more likely to be living with HIV and experience difficulty accessing HIV health services due to stigma and discrimination. Antiretroviral treatment and sustained viral suppression among individuals living with HIV is the last step in the continuum of HIV care, which has been shown to improve health outcomes and decrease the risk of onward transmission of HIV.

METHODS

To calculate the numerator and denominator for antiretroviral therapy (ART) coverage estimates among MSM and FSW living with HIV, the Priority Locations for AIDS Control Efforts methods were modified to include individual quantitative interviews, health service assessment and mapping, and size estimation in 7 cities in Cameroon. MSM and FSW were recruited using peer referral and venue-based sampling. The numerator was calculated from interviews with MSM and FSW. Population size estimation of MSM and FSW was used to determine the denominator.

RESULTS

Antiretroviral coverage varied by site from 0% to 25% among HIV infected MSM and FSW. ART provision to the general population was reported at a significantly greater proportion of HIV health centers (56.5%) than ART provision to MSM and FSW populations (13.2%).

CONCLUSIONS

The majority of MSM and FSW living with HIV and eligible for treatment in Cameroon are not connected to ART care. Additionally, ART provision for MSM and FSW at HIV health centers is insufficient. Characterizing effective strategies to reach optimal levels of engagement in the continuum of HIV care among MSM and FSW is essential for an AIDS-free generation for Cameroon.

Improving hospital-based quality of care by reducing HIV-related stigma: evaluation results from Vietnam

Operations Research conducted at four hospitals in Vietnam sought to reduce HIV-related stigma and discrimination among hospital workers. The quasi-experimental study compared effects of focusing on 'fear-based' stigma (stemming from lack of knowledge) versus both fear-based and social stigma (stemming from moral judgments). Interventions included staff training (ranging from physicians to ward cleaners), hospital policy development, and supplies provision. At baseline (n = 795), reported stigma was substantial (e.g., about half of hospital workers indicated fear of casually touching PLHIV, and felt HIV was a punishment for bad behavior). By endline, stigma measures had improved significantly for both intervention groups (e.g., proportion reporting signs on beds indicating HIV status decreased from 51 to 24 % in Arm 1, and 31 to 7 % in Arm 2), with the combined intervention group showing greater effects. This study highlights successful strategies to reduce stigma, and thus, improve quality of care for PLHIV.

Risk factors for delayed entrance into care after diagnosis among patients with late-stage HIV disease in southern Vietnam

BACKGROUND

We surveyed HIV patients with late-stage disease in southern Vietnam to determine if barriers to access and service quality resulted in late HIV testing and delays from initial diagnosis to entry into HIV care.

METHODOLOGY

196 adult patients at public HIV clinics with CD4 counts less than 250 cells/mm3 completed a standardized questionnaire. We used multivariate analysis to determine risk factors for delayed entry into care, defined as >3 months time from diagnosis to registration.

RESULTS

Common reasons for delayed testing were feeling healthy (71%), fear of stigma and discrimination in the community (43%), time conflicts with work or school (31%), did not want to know if infected (30%), and fear of lack of confidentiality (27%). Forty-five percent of participants delayed entry into care with a median CD4 count of 65 cells/mm3. The most common reasons for delayed entry were feeling healthy (51%), fear of stigma and discrimination in the community (41%), time conflicts with work or school (33%), and fear of lack of confidentiality (26%). Independent predictors for delayed entry were feeling healthy (aOR 3.7, 95% CI 1.5-9.1), first positive HIV test at other site (aOR 2.9, CI 1.2-7.1), history of injection drug use (IDU) (aOR 2.9, 95% CI 1.1-7.9), work/school conflicts (aOR 4.3, 95% CI 1.7-10.8), prior registration at another clinic (aOR 77.4, 95% CI 8.6-697), detention or imprisonment (aOR 10.3, 95% CI 1.8-58.2), and perceived distance to clinic (aOR 3.7, 95% CI 1.0-13.7).

CONCLUSION

Delayed entry into HIV care in Vietnam is common and poses a significant challenge to preventing AIDS and opportunistic infections, decreasing mortality, and reducing HIV transmission. Improved linkages between testing and care are needed, particularly for patients who feel healthy, as well as incarcerated and drug-using populations who may face structural and social barriers to accessing care.

Validation of 2 Spanish-Language Scales to Assess HIV-Related Stigma in Communities

We report the psychometric properties of 2 Spanish-language scales designed to measure (1) opinions about HIV in the community and particularly among health care workers and (2) observed acts of stigma toward people living with HIV/AIDS (PLWHA) by health care workers. The Opinions about HIV Scale included 3 components (policy, avoidance, and empathy) and 9 items, while an adapted version of the HIV/AIDS Stigma Instrument-Nurse, designed to capture acts of stigma, included 2 components (discrimination related to clinical care and refusal to share or exchange food/gifts). Scales demonstrated good reliability and construct validity. Relative to community health workers, treatment supporters were more likely to have stigmatizing opinions related to avoidance and empathy. We offer 2 Spanish-language scales that could be used to identify populations with high levels of stigmatizing opinions and behaviors toward PLWHA. Formal training of health care workers, especially treatment supporters, may raise awareness and reduce stigma toward HIV.

Stigma related to sex work among men who engage in transactional sex with men in Ho Chi Minh City, Vietnam

OBJECTIVES

Male sex workers (MSW) in Vietnam face high levels of stigma related to sex work, which may be associated with depression and increased vulnerability to HIV.

METHODS

In 2010, 300 MSW completed a behavioral and psychosocial survey. Multivariable models assessed factors associated with sex work-related stigma and the association between stigma and depression.

RESULTS

Factors associated with increased stigma included having disclosed sexual orientation to healthcare workers (b 1.75, 95 % CI 0.69-2.80), meeting clients in the street/park (b 1.42, 95 % CI 0.32-2.52), and having been forced to have sex without a condom (b 2.36, 95 % CI 1.27-3.45). Factors associated with decreased stigma included meeting clients via the telephone or internet (b -1.26, 95 % CI -2.39 to -0.12) and receiving financial support from family or friends (b -1.31, 95 % CI -2.46 to -0.17). Stigma was significantly associated with increased odds of depression (AOR 1.07, 95 % CI 1.01-1.15).

CONCLUSIONS

Addressing stigma and depression in HIV prevention interventions is crucial for tailoring these programs to MSWs' needs, and may result in decreased HIV spread.

Implementing a stigma reduction intervention in healthcare settings

Introduction

Globally, HIV-related stigma is prevalent in healthcare settings and is a major barrier to HIV prevention and treatment adherence. Some intervention studies have showed encouraging outcomes, but a gap continues to exist between what is known and what is actually delivered in medical settings to reduce HIV-related stigma.

Methods

This article describes the process of implementing a stigma reduction intervention trial that involved 1760 service providers in 40 hospitals in China. Guided by Diffusion of Innovation theory, the intervention identified and trained about 15–20% providers as popular opinion leaders (POLs) to disseminate stigma reduction messages in each intervention hospital. The intervention also engaged governmental support in the provision of universal precaution supplies to all participating hospitals in the trial. The frequency of message diffusion and reception, perceived improvement in universal precaution practices and reduction in the level of stigma in hospitals were measured at 6- and 12-month follow-up assessments.

Results

Within the intervention hospitals, POL providers reported more frequent discussions with their co-workers regarding universal precaution principles, equal treatment of patients, provider-patient relationships and reducing HIV-related stigma. Service providers in the intervention hospitals reported more desirable intervention outcomes than providers in the control hospitals. Our evaluation revealed that the POL model is compatible with the target population, and that the unique intervention entry point of enhancing universal precaution and occupational safety was the key to improved acceptance by service providers. The involvement of health authorities in supporting occupational safety was an important element for sustainability.

Conclusions

This report focuses on explaining the elements of our intervention rather than its outcomes. Lessons learned from the intervention implementation will enrich the development of future programs that integrate this or other intervention models into routine medical practice, with the aim of reducing HIV-related stigma and improving HIV testing, treatment and care in medical settings.

Obstacles to the 'cleanliness of our race': HIV, reproductive risk, stratified reproduction, and population quality in Hanoi, Vietnam

This paper focuses on the interactions between medical professionals in Hanoi, Vietnam and their HIV-positive patients who desire children. Drawing on ethnographic research, we argue that despite ongoing state and civil society efforts to reduce discrimination against people living with HIV (PLHIV), doctors do stigmatize patients who choose to reproduce, even if the patients are found to have carefully considered all associated risks. While the effects of the Social Evils Campaign linger, the doctors' prejudicial stance towards PLHIV's reproductive desires and risks also reflects the messages communicated by the more recent governmental campaign on Population Quality. The result of this stigmatization is a stratification of reproduction among the Vietnamese citizenry whereby PLHIV are considered obstacles to 'the cleanliness of the race'.