Disparity in health care: HIV, stigma, and marginalization in Nepal

Association between Sociodemographic Factors and Condom Use among Migrant Sex Workers in Chiang Mai, Northern Thailand

Thailand has the highest HIV burden in the Asia-Pacific region, with the majority of cases occurring in specific populations. Migrant Sex Workers (MSWs) in Thailand are an important population for HIV risk, yet there has been limited literature on this group and their protective sexual behavior. A cross-sectional study was conducted among 396 MSWs 18−49 years old from 23 sex work-identified venues in Chiang Mai. Participants were surveyed on their own sociodemographic information, health behavior, sexual risk behavior, quality of life, and depression. Male respondents were significantly younger than females (p = 0.003). Most respondents were from Myanmar and were ethnic Shan. In the month preceding the survey, 17.0% of MSWs had consistent condom use with regular partners, 53.7% with casual partners, and 87.9% with clients. Condom use was least practiced with regular partners and most practiced with clients (17% and 87.9%, respectively; p < 0.001). There was a significant positive association between condom use and starting high school (χ2 = 8.08, p = 0.018). Education was the only variable that was significantly correlated with condom use with any sexual partner (OR = 0.41; 95%CI 0.20−0.82). Findings of the study indicate that further efforts are needed to promote condom use among migrant sex workers and their sexual partners in Thailand.

'Staying alive' with antiretroviral therapy: a grounded theory study of people living with HIV in Peru

BACKGROUND

To achieve an optimal quality of life through chronic disease management, people living with HIV (PLHIV) must adhere to antiretroviral therapy (ART). ART has been available throughout Peru since 2004 without cost in all regions; yet only 60% (43 200) of PLHIV receive ART and 32% are virally suppressed. Despite the low adherence, little is known about the experience of PLHIV with ART adherence in the context of Latin America.

METHODS

A constructivist grounded theory design was used to understand the ART adherence experiences of PLHIV in Northern Peru. Unstructured interviews were conducted with 18 participants resulting in theoretical saturation. All interviews were recorded, immediately transcribed and analysed concurrently with data collection using constant comparative analysis with Atlas.ti (V.8) software. Rigour was maintained through openness, reflexivity, audit trail, memo writing, debriefings, member checks and positionality.

RESULTS

The core category 'staying alive' emerged through the interaction of four categories, including: (1) overcoming barriers; (2) working with the healthcare team; (3) tailoring self-care strategies; and (4) appreciating antiretrovirals. Adherence is not a spontaneous outcome, instead, the surprise of HIV diagnosis transitions to living with HIV as a chronic disease. The healthcare team helps PLHIV realise ART is their life source by enhancing, supporting and facilitating self-care and overcoming barriers.

CONCLUSION

Adherence emerges from experiential learning as PLHIV recognised ART as their life source in balance with their desire to continue living a normal life. Social support and healthcare team interventions help PLHIV implement tailored self-care strategies to overcome personal, social, and structural barriers to adherence. Healthcare professionals need to recognise the challenges confronted by PLHIV as they learn how to continue living while trying to stay alive.

Healthcare Seeking Intention if Diagnosed with HIV Among Young MSM in Taiwan: A Theory-Based Comparison by Voluntary Counseling and Testing Experience

The number of HIV cases in Taiwan exceeded 30,000 in 2016. Per the UNAIDS 90-90-90 target, 81% of people living with HIV should receive medication. However, numerous previous studies focused on adherence rather than the initial healthcare seeking intention if diagnosed with HIV (HIV HSI). Based on the Theory of Planned Behavior (TPB), anonymous online survey data were collected from December 2016 through February 2017 from 2709 young MSM (YMSM) ages 15-39. Multivariate logistic regression found the significant factors and strengths of associations with HIV HSI varied by their HIV voluntary counseling and testing (VCT) experience. YMSM without VCT experience perceiving high support from salient others (AOR = 1.28) and high control under facilitating conditions (AOR = 2.73) had higher HIV HSI. YMSM with VCT experience perceiving high control under facilitating (AOR = 1.79) and constraining (AOR = 1.54) conditions had higher HIV HSI. Regardless of VCT experience, YMSM with positive attitudes toward positive healthcare seeking outcomes (AOR = 3.72-3.95) had highest HIV HSI, highlighting the importance of increasing positive outcome expectations in YMSM.

'We keep her status to ourselves': experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine

In HIV-discordant relationships, the HIV-negative partner also carries the burden of a stigmatised disease. For this reason, couples often hide their HIV-discordant status from family, friends and community members. This perpetuates the silence around HIV-discordant relationships and impacts on targeted HIV prevention, treatment and counselling efforts. This article reports on experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine. During 2008, HIV-discordant couples who had been in a relationship for at least one year were recruited purposively through health-care providers and civil society organisations in the three countries. Participants completed a brief self-administered questionnaire, while semi-structured interviews were conducted with each partner separately and with both partners together. Interviews were analysed using thematic content analysis. Fifty-one couples were recruited: 26 from South Africa, 10 from Tanzania, and 15 from Ukraine. Although most participants had disclosed their HIV status to someone other than their partner, few were living openly with HIV discordance. Experiences of stigma were common and included being subjected to gossip, rumours and name-calling, and HIV-negative partners being labelled as HIV-positive. Perpetrators of discrimination included family members and health workers. Stigma and discrimination present unique and complex challenges to couples in HIV sero-discordant relationships in these three diverse countries. Addressing stigmatisation of HIV-discordant couples requires a holistic human rights approach and specific programme efforts to address discrimination in the health system.

Influence of social experiences in shaping perceptions of the Ebola virus among African residents of Hong Kong during the 2014 outbreak: a qualitative study

INTRODUCTION

The outbreak of Ebola virus disease (EVD) in Africa in 2014 attracted worldwide attention. Because of the high mortality rate, marginalised social groups are vulnerable to disease-associated stigmatisation and discrimination, according to the literature. In Hong Kong, ethnic minorities such as Africans are often disadvantaged groups because of their low position in the social hierarchy. In 2011, approximately 1700 Africans were residing in Hong Kong. Their overseas experiences during the EVD outbreak were not well documented. Therefore, this study investigated the EVD-associated stigmatisation experiences of African residents of Hong Kong with chronic illnesses, and how these experiences shaped their perceptions of EVD.

METHODS

A qualitative design with 30 in-depth semistructured interviews was conducted with chronically ill African residents of Hong Kong.

RESULTS

The interview data showed that the sampled Africans often experienced stigmatisation in their workplaces and in the community during the EVD outbreak. Their experiences of EVD-associated stigma were correlated to the embedded social and cultural values regarding ethnic minorities in Hong Kong. These experiences of being stigmatised shaped the perceptions of the Africans of EVD, leading them to view EVD as shameful and horrifying. They also perceived EVD as retribution and was introduced by Westerners. The participants' perceptions of EVD influenced their responses to and behaviour towards EVD, which may have posed potential threats to Hong Kong's public health.

CONCLUSIONS

The EVD outbreak was not the only cause of the participants' stigmatisation; rather, their EVD-associated experiences were a continuation and manifestation of the embedded social and cultural values regarding ethnic minorities in Hong Kong. The experiences of being stigmatised shaped the participants' perceptions of EVD. Because of their marginalised social position and isolation from the main community, the participants had extremely limited access to reliable information about EVD. As a result, they used their own cultural beliefs to understand EVD, which might have ultimately influenced their health behaviours. The experiences of the participants showed that ethnic minorities in Hong Kong were in need of more culturally responsive social and health care support to obtain reliable information about the nature of and preventive measures against EVD.

'Are We Not Human?' Stories of Stigma, Disability and HIV from Lusaka, Zambia and Their Implications for Access to Health Services

BACKGROUND

The advent of anti-retroviral therapy (ART) in Southern Africa holds the promise of shifting the experience of HIV toward that of a manageable chronic condition. However, this potential can only be realized when persons living with HIV are able to access services without barriers, which can include stigma. Our qualitative study explored experiences of persons living with disabilities (PWD) in Lusaka, Zambia who became HIV-positive (PWD/HIV+).

METHODS AND FINDINGS

We conducted interviews with 32 participants (21 PWD/HIV+ and 11 key informants working in the fields of HIV and/or disability). Inductive thematic analysis of interview transcripts was informed by narrative theory. Participants' accounts highlighted the central role of stigma experienced by PWD/HIV+, with stigmatizing attitudes closely linked to prevailing societal assumptions that PWD are asexual. Seeking diagnostic and treatment services for HIV was perceived as evidence of PWD being sexually active. Participants recounted that for PWD/HIV+, stigma was enacted in a variety of settings, including the queue for health services, their interactions with healthcare providers, and within their communities. Stigmatizing accounts told about PWD/HIV+ were described as having important consequences. Not only did participants recount stories of internalized stigma (with its damaging effects on self-perception), but also that negative experiences resulted in some PWD preferring to "die quietly at home" rather than being subjected to the stigmatizing gaze of others when attempting to access life-preserving ART. Participants recounted how experiences of stigma also affected their willingness to continue ART, their willingness to disclose their HIV status to others, as well as their social relations. However, participants also offered counter-stories, actively resisting stigmatizing accounts and portraying themselves as resilient and resourceful social actors.

CONCLUSIONS

The study highlights a significant barrier to healthcare experienced by PWD/HIV+, with important implications for the future design and equitable delivery of HIV services in Zambia. Stigma importantly affects the abilities of PWD/HIV+ to manage their health conditions.

Social determinants of poor knowledge on HIV among Nepalese males: findings from national survey 2011

Since the first case detection in Nepal in 1988, the number of cases of Human Immunodeficiency Virus (HIV) are increasing. Limited studies exist concerning the knowledge on HIV among the Nepalese men. This study aimed to examine the social determinants of poor knowledge on HIV among Nepalese men aged 15-49 years based on Nepal Demographic and Health Survey (NDHS), 2011. This study is based on the secondary data of NDHS 2011. HIV knowledge was assessed by using structured qustionnaire. A Chi square test followed by logistic regression was performed to find the association of social determinants with outcome variables. Of the 3,991 participants, 1,217 (30.5%) had comprehensive knowledge and the majority (69.5%) had poor knowledge on HIV. More than half (54.6%) reported that mosquito bite can transmit HIV and 26.5% reported that sharing food can transmit HIV. Respondents who were uneducated [aOR 10.782; 95% CI (6.673-17.421)], were manual workers [aOR 1.442; 95% CI (1.152-1.804)], were poor [aOR 1.847; 95% CI (1.350-2.570)]; lived in the the Eastern region [aOR 2.203(1.738-2.793)], or in the Mountain [aOR 1.542; 95% CI (1.132-1.864)]; did not read newspaper/magazine at all [aOR 1.454; 95% CI (1.142-1.851)] and did not listen to the radio at all [aOR 1.354; 95% CI (1.046-1.752)] were likely to have poor knowledge of HIV. HIV prevention programs should include men incorporating appropriate educatoinal intervention to increase their knowledge.

Prison, a missing target to address issues related to drug detoxification and rehabilitation: Nepalese experiences

PURPOSE

Drug use has numerous consequences on health, the economy, culture and the peace and security of families and communities. Drug users often engage in various criminal activities, including drug dealing, to sustain their drug use. Under Nepalese law, consumption, possession and sale of drugs are illegal, which increases the risk of incarceration for drug users.

DESIGN/METHODOLOGY/APPROACH

Using a phenomenological/qualitative approach, the paper explores how various activities can lead to the arrest of drug users, how they cope without taking drugs in custody and prison and how they plan abstinence after release.

FINDINGS

Participants engaged in various categories of criminal activity, including stealing, looting, etc. Most of the drug users were in custody and prison at least once. Drug use relapses led the participants to re-engage in criminal activities including drug dealing. Parents were often overburdened by their sons and daughter's drug use and were worried about their repeated relapses. Finally, some parents negotiated with their sons and daughters to keep them in prison where they would be able to stay without taking drugs and their involvement in crimes and conflicts would decrease.

ORIGINALITY/VALUE

Keeping substance abusers in prison does not appear to be an effective strategy, as many participants relapse after release from prison. However, a prison-based educational and health promotion strategy would be beneficial for drug users to develop knowledge and skills on staying drug-free. However, to date, no effort has been made to provide such services to drug users and develop their coping strategy after release.

Injection drug use and HIV antiretroviral therapy discontinuation in a Canadian setting

We investigated whether drug-related behaviors predicted antiretroviral therapy (ART) discontinuation among a cohort of injection drug users (IDU) in a Canadian setting. Cox regression analyses were used to investigate the impact of drug use patterns on rates of ART discontinuation among a sample of HIV-positive IDU in Vancouver, Canada between May 1996 and April 2008. In total, 408 HIV-positive IDU initiated ART during the study period, among whom 257 (63.0%) discontinued ART at least once. Rates of ART discontinuation were not significantly elevated among those who reported ongoing injection of heroin, cocaine, or other illicit drugs in comparison to those who reported not injecting drugs. However, public drug use was significantly predictive of ART discontinuation. Our findings may contribute to a reconsideration of the role of active drug use in determining retention in ART programs among IDU.

Risk of resistance to highly active antiretroviral therapy among HIV-positive injecting drug users: a meta-analysis

Although highly active antiretroviral therapy (HAART) is an effective treatment for HIV, many physicians withhold this treatment from HIV-positive injecting drug users (IDUs) because of fears of non-adherence and consequent development of antiretroviral resistance. Little is known, however, about whether the rates of resistance differ between IDUs and non-IDUs. We did a meta-analysis of studies that compared antiretroviral resistance rates in IDUs (current or previous) with those in HIV-positive patients infected by other routes and who had never injected drugs. We used a random-effects model to investigate overall resistance rates and resistance to individual drug classes. Of 181 potential studies, 27 were eligible for review. We were able to extract data from 14 studies, but two were excluded because of a very small sample size of IDUs or data being available only from a secondary analysis. Thus we included 12 studies in the meta-analysis, involving 9055 patients, of which 2054 (23%) were IDUs. The risk of development of antiretroviral resistance did not differ significantly between IDU and non-IDU (odds ratio 1.04, 95% CI 0.74-1.45, p=0.84). Rates of loss to follow-up and virological failure were similar in IDU and non-IDU samples. Existing evidence does not support the common practice of withholding antiretroviral therapy from HIV-positive IDU on the basis of an elevated risk of antiretroviral resistance. Therapeutic guidelines should consider reassessment of this issue.

Experiences of stigma in healthcare settings among adults living with HIV in the Islamic Republic of Iran

Background

People living with HIV (PLHIV) sometimes experience discrimination. There is little understanding of the causes, forms and consequences of this stigma in Islamic countries. This qualitative study explored perceptions and experiences of PLHIV regarding both the quality of healthcare and the attitudes and behaviours of their healthcare providers in the Islamic Republic of Iran.

Methods

In-depth, semi-structured interviews were held with a purposively selected group of 69 PLHIV recruited from two HIV care clinics in Tehran. Data were analyzed using the content analysis approach.

Results and discussion

Nearly all participants reported experiencing stigma and discrimination by their healthcare providers in a variety of contexts. Participants perceived that their healthcare providers' fear of being infected with HIV, coupled with religious and negative value-based assumptions about PLHIV, led to high levels of stigma. Participants mentioned at least four major forms of stigma: (1) refusal of care; (2) sub-optimal care; (3) excessive precautions and physical distancing; and (4) humiliation and blaming. The participants' healthcare-seeking behavioural reactions to perceived stigma and discrimination included avoiding or delaying seeking care, not disclosing HIV status when seeking healthcare, and using spiritual healing. In addition, emotional responses to perceived acts of stigma included feeling undeserving of care, diminished motivation to stay healthy, feeling angry and vengeful, and experiencing emotional stress.

Conclusions

While previous studies demonstrate that most Iranian healthcare providers report fairly positive attitudes towards PLHIV, our participants' experiences tell a different story. Therefore, it is imperative to engage both healthcare providers and PLHIV in designing interventions targeting stigma in healthcare settings. Additionally, specialized training programmes in universal precautions for health providers will lead to stigma reduction. National policies to strengthen medical training and to provide funding for stigma-reduction programming are strongly recommended. Investigating Islamic literature and instruction, as well as requesting official public statements from religious leaders regarding stigma and discrimination in healthcare settings, should be used in educational intervention programmes targeting healthcare providers. Finally, further studies are needed to investigate the role of the physician and religion in the local context.