Stigma and intersectionality: a systematic review of systematic reviews across HIV/AIDS, mental illness, and physical disability

Age-related experiences of diverse older women living with HIV: A scoping review protocol informed by intersectionality

INTRODUCTION

Older women living with HIV often go unnoticed due to societal biases and stigmas. Despite a rise in cases among older women, there is limited research on the psychosocial factors impacting their experiences. Aging complexities compounded by HIV and menopause affect these women's health, while factors like mental health impact, changing support networks, and ageism with HIV stigma influence their well-being. Existing studies mostly compare older HIV-positive individuals without considering gender and intersectional identities, limiting understanding of their unique experiences. The scarcity of research addressing age-related differences from diverse perspectives delays the development of tailored treatments and interventions.

OBJECTIVES

The study aims to comprehensively explore the age-related experiences of older women with HIV through three sub-questions that address (1) Key experiences, medical and social challenges, and strengths; (2) Impact of intersectional identities on their experiences; and (3) Gaps and limitations in current research.

METHODS

Utilizing a scoping review approach, the study seeks to map existing literature, employing a theoretical framework rooted in Sex- and Gender-Based Analysis Plus (SGBA+). Articles focusing on the age-related experiences of older women living with HIV aged 50 and above will be included. The study selection process will involve two independent reviewers screening articles based on pre-established inclusion criteria. Data extraction and synthesis will follow, analyzing the influence of sex, gender, and other identities on experiences.

DISCUSSION

The study's comprehensive approach aims to bridge gaps in understanding older women's HIV experiences, emphasizing intersectionality. While limited to English-language peer-reviewed articles, this review seeks to offer valuable insights for healthcare, policy, and research, potentially fostering positive change in the lives of diverse older women living with HIV.

Intersectional Structural Stigma: A Qualitative Study With Persons Experiencing Homelessness in the Southwest United States

This study explored the manifestations of intersectional structural stigma and stigma-reducing strategies in the context of health among a diverse group of persons experiencing homelessness in the southwest United States. Purposive sampling was used to recruit youth (ages 12-17), young adults (ages 18-24), adults (ages 25 years old or older), women with children, veterans, and males over 60 years old who self-identified as homeless. Grounded theory was applied, and thematic analysis was conducted using data collected from seven focus groups (n = 76 participants). A model of intersectional stigma was adapted from the Health Stigma and Discrimination Framework. This adaptation depicts pathways for addressing intersectional stigmatization experienced by individuals with multiple intersecting identities across the interpersonal, organization, and community levels not explicitly addressed in the Health Stigma and Discrimination Framework. At the interpersonal level, participants indicated they experienced stigmatizing behaviors and practices by service providers due primarily to their identities related to economic or unhoused statuses, gender, age, and mental health. Facilitators of intersectional stigma were identified through organization practices and processes. Multiple stigmatized identities due to social beliefs also facilitated stigmatization at the community level. Health outcomes influenced by stigmatization were also identified. Despite the stigmatization they experienced, participants discussed stigma-reducing strategies related to community assets, medical care, and destigmatizing practices by service providers.

Stigma and fear of getting sick in the care of people living with HIV: an exploratory systematic review

The aim of the present study was to explore the stigma and fear of getting sick in health professionals who treat people living with HIV. An exploratory systematic review was conducted. The search was limited to the presence of stigma and fear of getting sick on the part of healthcare workers who treat people living with HIV, documented by the health workers or patients themselves. No language restriction was made and systematic reviews, comments or communications were excluded. The sources of information were Scopus, PubMed/MEDLINE, Science Direct, and the CENTRAL Registry, from the last 5 years. The quality of the evidence was assessed with an adapted tool and the synthesis of the results was carried out using a narrative synthesis approach. Twenty-three articles were included, which related structural stigma, stigma by health professionals and fear of getting sick. Among the findings, data stood out such as that more than 50% of patients reported having experienced discrimination due to HIV and even accumulated stigma for other additional causes. Stigma enacted in healthcare settings was related to suboptimal adherence to treatment (OR 1.38; 95% CI: 1.03-1.84; p=0.028). Stigma is a structural barrier in the care of people living with HIV and generates a psychological, physical, and social health impact for these people. Some limitations of the present study are that, despite searching the major databases, important manuscripts may have been left out. Additionally, there are regions that are not represented in this review because no manuscripts from those areas were found.

HIV-Related Stigma and Multidimensional Frailty Among Older Latinos With HIV

Introduction: Frailty is a geriatric syndrome of increased vulnerability to stressors marked by a higher risk for poor health outcomes. HIV-related stigma is a stressor for Latino people with HIV (PWH) and an important barrier to HIV care. This study examines the association between HIV-related stigma and multidimensional frailty among older Latino PWH. Methods: A cross-sectional design with 120 Latino PWH aged 50 and older was used. Self-reported questionnaires were administered to assess multidimensional frailty (Tilburg Frailty Indicator) and HIV-related stigma (HIV stigma scale). Results: Participants were 59.1 ± 7.0 years old, primarily White-Hispanic (85.00%, n = 102), single (48.33%, n = 58), and male (73.30%, n = 88). Nearly half of the participants were frail (45.85%, n = 55). Compared to non-frail, frail individuals had significantly higher scores in the total HIV-related stigma (M = 98.5 ± 24.7 vs. M = 85.3 ± 25.6, p = .020) and all subscales. The odds of multidimensional frailty were 1.021 times higher for people with higher HIV-related stigma scores (p = .007). This association remained significant after adjustment for income and comorbidities (p = .049). Conclusions: HIV-related stigma among older Latino PWH was significantly associated with their odds of being frail. Efforts to prevent multidimensional frailty should consider addressing HIV-related stigma through age-appropriate and culturally tailored resources for this group.

Intersectional HIV- and Depression-Related Stigma Among People with HIV Entering HIV Care in Cameroon

Mental health-related stigma is a prominent barrier to improved mental health outcomes globally and may be particularly harmful to populations with other stigmatized identities. We aimed to understand intersectional depression- and HIV-related stigma among people with HIV (PWH) entering HIV care in Cameroon. Using baseline data from a cohort of PWH entering HIV care in Cameroon between 2019 and 2020, we characterized depression- and HIV-related stigma in the population overall and by sociodemographic sub-group. We also explored substantively meaningful variation in stigma endorsement by depressive symptom severity (Patient Health Questionnaire-9 [PHQ-9]) and causal attribution of depression. Among those with elevated depressive symptoms (PHQ-9 scores > 4), we estimated the association between stigma type and depressive symptom severity using binomial regression. Among 398 participants, 49% endorsed low HIV- and depression-related stigma (N = 195), 10% endorsed high HIV- and depression-related stigma (N = 38), 29% endorsed high depression-related stigma only (N = 116), and 12% endorsed high HIV-related stigma only (N = 49). Respondents with and without heightened depressive symptoms commonly believed depressive symptoms were caused by HIV (N = 140; 32.9%). Among those with elevated depressive symptoms, the prevalence of moderate to severe symptoms was higher among those endorsing high HIV-related stigma only (prevalence ratio 1.55; 95% confidence interval: 1.01, 2.37) compared to those reporting low HIV- and depression-related stigma. HIV- and depression-related stigma are both common among PWH entering HIV care in Cameroon. The consistent association between HIV-related stigma and poor psychosocial well-being among people with HIV necessitates the urgent scale-up of evidence-based HIV-related stigma interventions specifically.

Multimorbid life expectancy across race, socio-economic status, and sex in South Africa

Multimorbidity is increasing globally as populations age. However, it is unclear how long individuals live with multimorbidity and how it varies by social and economic factors. We investigate this in South Africa, whose apartheid history further complicates race, socio-economic, and sex inequalities. We introduce the term 'multimorbid life expectancy' (MMLE) to describe the years lived with multimorbidity. Using data from the South African National Income Dynamics Study (2008-17) and incidence-based multistate Markov modelling, we find that females experience higher MMLE than males (17.3 vs 9.8 years), and this disparity is consistent across all race and education groups. MMLE is highest among Asian/Indian people and the post-secondary educated relative to other groups and lowest among African people. These findings suggest there are associations between structural inequalities and MMLE, highlighting the need for health-system and educational policies to be implemented in a way proportional to each group's level of need.

St. Louis Enhancing Engagement and Retention in HIV/AIDS Care (STEER): a participatory intersectional needs assessment for intervention and implementation planning

Background Missouri is one of seven priority states identified by the Ending the HIV Epidemic Initiative, and St. Louis contains almost half of the people living with HIV (PLWH) in Missouri. As St. Louis has a marked history of structural racism and economic inequities, we utilized the Intersectionality Based Policy Analysis (IBPA) framework to guide a participatory needs assessment for planning and program development. Methods The planning team included researchers, the lead implementer from our community partner, and two community representatives, and had biweekly 60-90 minute meetings for 18 months. The planning team discussed and approved all research materials, reviewed and interpreted results, and made decisions about outreach, recruitment, conduct of the needs assessment and development of the planned intervention. The needs assessment integrated information from existing data, (1) interviews with (a) PLWH (n=12), (b) community leaders (n=5), (c) clinical leaders (n=4), and (d) community health workers (CHWs) (n=3) and (e) CHW supervisors (n=3) who participated in a Boston University-led demonstration project on CHWs in the context of HIV and (2) focus groups (2 FG, 12 participants) with front line health workers such as peer specialists, health coaches and outreach workers. A rapid qualitative analysis approach was used for all interviews and focus groups. Results The IBPA was used to guide team discussions of team values, definition and framing of the problem, questions and topics in the key informant interviews, and implementation strategies. Applying the IBPA framework contributed to a focus on intersectional drivers of inequities in HIV services. The effective management of HIV faces significant challenges from high provider turnover, insufficient integration of CHWs into care teams, and organizational limitations in tailoring treatment plans. Increasing use of CHWs for HIV treatment and prevention also faces challenges. People living with HIV (PLWH) encounter multiple barriers such as stigma, lack of social support, co-morbidities, medication side effects and difficulties in meeting basic needs. Conclusions Addressing intersectional drivers of health inequities may require multi-level, structural approaches. We see the IBPA as a valuable tool for participatory planning while integrating community engagement principles in program and implementation design for improving HIV outcomes.

A Fall Prevention Feasibility Trial for People With HIV and Alcohol Use

Alcohol contributes to higher fall risk in people living with HIV (PLWH), yet fall prevention trials for PWH with alcohol use are lacking. To assess the feasibility of conducting a randomized controlled trial of a 10-week online fall prevention intervention tailored for PLWH with alcohol use. The intervention consisted of weekly virtual group discussions, individual phone check-ins, and home exercises. Of those eligible, 53.5% (23/43) enrolled (12 to the intervention and 11 to control). Mean age was 58 years; 82.6% had a past 6-month fall; 65.2% had alcohol use disorder; and 95.7% completed postintervention assessments. The intervention was highly rated (Client Satisfaction Questionnaire-8 score M = 30.4, SD = 1.6) with a wide range of group and individual phone session attendance. Preliminary analyses suggest the intervention may reduce the odds of falling and alcohol use frequency. Findings support the feasibility of a larger randomized trial. ClinicalTrials.gov Identifier: NCT04804579.

Drug Use-Related Discrimination in Healthcare Settings and Subsequent Emergency Department Utilization in a Prospective Cohort Study of People With a History of Injection Drug Use

BACKGROUND

 People with a history of injection drug use face discrimination in healthcare settings that may impede their use of routine care, leading to greater reliance on the emergency department (ED) for addressing health concerns. The relationship between discrimination in healthcare settings and subsequent ED utilization has not been established in this population.

METHODS

 This analysis used longitudinal data collected between January 2014 and March 2020 from participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based observational cohort study of people with a history of injection drug use in Baltimore, Maryland. Logistic regressions with generalized estimating equations were used to estimate associations between drug use-related discrimination in healthcare settings and subsequent ED utilization for the sample overall and six subgroups based on race, sex, and HIV status.

RESULTS

 1,342 participants contributed data from 7,289 semiannual study visits. Participants were predominately Black (82%), mostly male (66%), and 33% were living with HIV. Drug use-related discrimination in healthcare settings (reported at 6% of study visits) was positively associated with any subsequent ED use (OR = 1.40, 95% CI: 1.15-1.72). Positive associations persisted after adjusting for covariates, including past sixth-month ED use and drug use, among the overall sample (aOR = 1.28, 95% CI: 1.04-1.59) and among some subgroups.

CONCLUSIONS

 Drug use-related discrimination in healthcare settings was associated with greater subsequent ED utilization in this sample. Further exploration of mechanisms driving this relationship may help improve care and optimize healthcare engagement for people with a history of injection drug use.

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.

Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa

OBJECTIVES

Sexual and gender minority (SGM) populations in sub-Saharan Africa (SSA) are disproportionately impacted by HIV and often face multiple HIV-related stigmas. Addressing these stigmas could reduce SGM HIV vulnerability but little is known about how the stigmas operate and intersect. Intersectional stigma offers a lens for understanding the experiences of stigmatised populations and refers to the synergistic negative health effects of various systems of oppression on individuals with multiple stigmatised identities, behaviours or conditions. This review aims to (1) assess how often and in what ways an intersectional lens is applied in HIV-related stigma research on SGM populations in SSA and (2) understand how intersectional stigma impacts HIV risk in these populations.

DESIGN

Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews.

DATA SOURCES

Public health and regional databases were searched in 2020 and 2022.

ELIGIBILITY CRITERIA

Articles in French and English on HIV-related stigma and HIV outcomes among men who have sex with men, women who have sex with women and/or transgender individuals in SSA.

DATA EXTRACTION AND SYNTHESIS

Articles were screened and extracted twice and categorised by use of an intersectional approach. Study designs and stigma types were described quantitatively and findings on intersectional stigma were thematically analysed.

RESULTS

Of 173 articles on HIV-related stigma among SGM in SSA included in this review, 21 articles (12%) applied an intersectional lens. The most common intersectional stigmas investigated were HIV and same-sex attraction/behaviour stigma and HIV, same-sex attraction/behaviour and gender non-conformity stigma. Intersectional stigma drivers, facilitators and manifestations were identified across individual, interpersonal, institutional and societal socioecological levels. Intersectional stigma impacts HIV vulnerability by reducing HIV prevention and treatment service uptake, worsening mental health and increasing exposure to HIV risk factors.

CONCLUSION

Intersectional approaches are gaining traction in stigma research among SGM in SSA. Future research should prioritise quantitative and mixed methods investigations, diverse populations and intervention evaluation.

Leaving no one behind? Addressing inequitable HIV outcomes by attending to diversity: A qualitative study exploring the needs of LGBTQI+ young people living with HIV in Zimbabwe

Leaving nobody behind in the fight to end the HIV epidemic as a public health threat depends on addressing inequities in optimal HIV outcomes. Consistently overlooked in research, policy and programming are young lesbian, gay, bisexual, transgender, queer/questioning and intersex (LGBTQI+) people who are living with HIV. This study engaged young LGBTQI+ people in Zimbabwe to better understand their experiences of living with HIV and the support they need. Between September 2022 and February 2023, we conducted qualitative research with 14 LGBTQI+ young people (18-24 years), (two focus group discussions and in-depth interviews with 5/14). All 14 participants were accessing a LGBTQI+ HIV support group at Zvandiri ('As I Am'), a well-established community-based HIV program. We conducted thematic analysis and key findings informed the collaborative development of internal activities to further enhance inclusivity of LGBTQI+ young people within Zvandiri's programs. There was consensus among participants that being LGBTQI+ and living with HIV leads to "double stigma and double trouble", involving physical and verbal harassment, social exclusion and family rejection. Participants concealed their LGBTQI+ identity and HIV status in most situations, and many withheld their HIV status in LGBTQI+ social spaces, including community-led LGBTQI+ services. This negatively impacted their psychosocial well-being and social connectedness. Participants described positive experiences of Zvandiri. Interacting with others living with HIV in a destigmatising environment promoted self-acceptance. However, reflecting their prevailing experiences, participants were cautious about revealing their sexuality and/or gender identity at Zvandiri outside of their support group. Ensuring equitable access to HIV care, including mental health support, relies on understanding the challenges experienced by those most marginalised. Critically important is understanding the impact of intersectional stigma on LGBTQI+ young peoples' social lives, and their access to services. Community-based HIV support programs are well-positioned to support and advance this group's health rights.

How does intersectionality impact the quality of healthcare services for Black women living with HIV?

Women with HIV are affected more than men by intersecting discriminations. For Black women, additional discrimination can have a detrimental effect on their HIV care. An extended literature review of primary research studies was undertaken to explore the issues and the impact of intersectionality on Black women with HIV. Electronic databases were searched for studies published since antiretroviral treatment became recognised to be effective, and eight studies met detailed inclusion and exclusion criteria. Critical appraisal led to the identification of three themes: discrimination; stigmatisation; and racism. The findings suggest that while Black women with HIV reported barriers to health care because of intersectionality, older women who felt confident in their self-identity were more able to cope with issues around this. Knowledge of the factors affecting these women will enable health professionals to deliver person-centred care.

Depressive disorder at the household level: prevalence and correlates of depressive symptoms among household members

BACKGROUND

Globally, an estimated five percent of adults have major depressive disorder. However, little is known about the relationship between these individuals' depressive symptoms and their household members' mental health and well-being.

OBJECTIVES

We aimed to investigate the prevalence and predictors of depressive symptoms among adult household members of patients living with major depressive disorder in Neno District, Malawi.

METHODS

As part of a cluster randomized controlled trial providing depression care to adults with major depressive disorder, we conducted surveys with patients' household members (n = 236) and inquired about their overall health, depressive symptoms, disability, and social support. We calculated prevalence rates of depressive disorder and conducted multivariable linear regression and multivariable logistic regression analyses to assess correlates of depressive symptom severity and predictors of having depressive disorder (PHQ-9), respectively, among household members.

RESULTS

We observed that roughly one in five household members (19%) screened positive for a depressive disorder (PHQ-9 > 9). More than half of household members endorsed six or more of the nine symptoms, with 68% reporting feeling 'down, depressed, or hopeless' in the prior two weeks. Elevated depression symptom severity was associated with greater disability (β = 0.17, p < 0.001), less social support (β = -0.04, p = 0.016), and lower self-reported overall health (β = 0.54, p = 0.001). Having depressive disorder was also associated with greater disability (adjusted Odds Ratio [aOR] = 1.12, p = 0.001) and less social support (aOR = 0.97, p = 0.024).

CONCLUSIONS

In the Malawian context, we find that depressive disorder and depression symptoms are shared attributes among household members. This has implications for both screening and treatment, and it suggests that mental health should be approached from the vantage point of the broader social ecology of the household and family unit.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT04777006) - March 2, 2021.

HIV epidemic, prevention technologies, and the new generations: trends and opportunities for epidemic response

The United Nations has underscored the possibility of ending the HIV epidemic as a public health problem. However, an increase in the incidence among adolescents and youth has indicated a greater distance between HIV responses and the specificities of the new generations, which can maintain the epidemic for an extended period. Regards this matter, it is debated that the provision of a range of preventive methods, even if highly effective, and a conservatism that has internalized stigma within government policies, hinder the proper and essential dialogue between current preventive policies and the needs of the new generations. These generations are marked by a social representation of AIDS as a mild disease, by new gender and sexuality performances, and by the search for a more critical role in affective and sexual encounters, which includes frequent use of dating apps and substances. The hierarchy of the delivery of prevention methods is presented as a proposal for a new policy, prioritizing pre-exposure prophylaxis (PrEP) and addressing the social determinants of the HIV epidemic, including strategies to mitigate stigma. The importance of the participation of adolescents and youth in constructing the policy and the need for an intersectoral response are also reinforced.

No evidence that social-democratic welfare states equalize valued outcomes for individuals with disabilities

It is acknowledged that generous welfare states can provide better outcomes to their populations in terms of objective and subjective indicators of well-being, yet there is little comparative evidence of the role that the welfare state regime plays in lessening disability-based inequalities. Using a large comparative data set of most European societies, Tukey's honestly significant difference and generalized Hausman tests for six welfare state regimes, we examine the assumption that social-democratic countries perform better in mitigating disability-based inequalities than conservative, liberal, Southern, Eastern European, and the former Soviet Union welfare state regimes. We compare the valued outcomes for individuals with and without disabilities regarding their education, labour market participation, material well-being, and life satisfaction. The main finding of this study is that the most generous welfare states in Europe do not perform better, and in some cases, perform worse, than other less comprehensive welfare state regimes in closing the gap in valued outcomes between individuals with disabilities and the rest of the population. We discuss potential explanations of these inequalities such as the nature of expectations and changing characteristics of welfare state regimes, and difficulties related to measuring disabilities across European societies.

Admitting the heterogeneity of social inequalities: intersectionality as a (self-)critical framework and tool within mental health care

Inequities shape the everyday experiences and life chances of individuals at the margins of societies and are often associated with lower health and particular challenges in accessing quality treatment and support. This fact is even more dramatic for those individuals who live at the nexus of different marginalized groups and thus may face multiple discrimination, stigma, and oppression. To address these multiple social and structural disadvantages, intersectional approaches have recently gained a foothold, especially in the public health field. This study makes an empirically informed argument for the merits of increasing the use of intersectional frameworks in the mental health field. In the mental health field, the potential for greater attention to multiple unjustified disadvantages appears to be of particular importance, as many mental health service users already face stigma and discrimination because of their mental health issues and thus may benefit particularly frequently and far-reachingly from effective problem awareness about multiple disadvantages. Intersectional approaches may help address the complexity, interdependence, and mutual constitution of social inequalities better than previous approaches that examined only one category of sociostructural stratification. By helping to identify the needs of those at the greatest risk of poor health, intersectional frameworks and tools can contribute not only to better address the needs of multiple disadvantaged individuals with mental health issues but also to the promotion of equity in the field of mental health, contributing to the reduction of health disparities.

Psychosocial stress and methamphetamine use: A mixed-methods study of intersectional stigma and Aboriginal and Torres Strait Islander methamphetamine use

BACKGROUND

Regular methamphetamine use can cause a range of physical, psychological and social harms. Stigma is one factor that impacts engagement and successful completion of treatment. In Australia, Aboriginal and Torres Strait Islander people who regularly use methamphetamine experience multiple stigmas, which further compounds access to treatment and quality of life. This paper explores the cumulative and compounding effects of participating in a stigmatised activity such as illicit drug use in relation to the stigma experienced by Aboriginal and Torres Strait Islander people as a population marginalised through colonisation.

METHODS

Ten sites nationally participated in a cross-sectional survey measuring a range of factors including psychosocial stress in methamphetamine users. The survey sample size was 734, with 59% identifying as Aboriginal and Torres Strait Islander (n = 433). In addition, a total of 147 mainly Aboriginal and Torres Strait Islander people who use methamphetamine, community and family members, and service providers took part in a total of 19 focus groups and 7 interviews.

RESULTS

Aboriginal and Torres Strait Islander participants experienced multiple psychosocial stressors at significantly higher rates than non-Indigenous participants. These stressors include diminished access to health care (33%), experiences of racism (34%), grief and sorrow (39%), worry for family (46%), and child welfare experiences (46%). The qualitative findings highlight the cumulative impact of historical, political and social stressors on an already stigmatised population.

CONCLUSIONS

The findings of this unique analysis demonstrate the disruptive impact of methamphetamine use on the lives of those who use methamphetamines and their family members. They also illustrate challenges, such as stigma, that may confront those seeking assistance for drug-related issues. Aboriginal and Torres Strait Islander community involvement is necessary to provide support and education for the individual, the family, and the community as a whole. Stigma reduction is therefore a worthy target for intervention.

Stigma Toward Substance Dependence: Causes, Consequences, and Potential Interventions

Substance dependence is a prevalent and urgent public health problem. In 2021, 60 million Americans reported abusing alcohol within the month prior to being surveyed, and nearly 20 million Americans reported using illegal drugs (e.g., heroin) or prescription drugs (e.g., opioids) for nonmedical reasons in the year before. Drug-involved overdose rates have been steadily increasing over the past 20 years. This increase has been primarily driven by opioid and stimulant use. Despite its prevalence, drug dependence is one of the most stigmatized health conditions. Stigma has myriad negative consequences for its targets, including limiting their access to employment and housing, disrupting interpersonal relationships, harming physical and mental health, and reducing help-seeking. However, because research on stigma toward people with substance use disorders (SUDs) is relatively sparse compared with research on stigma toward other mental illnesses, the field lacks a comprehensive understanding of the causes and consequences of SUD stigma. Moreover, it remains unclear how, if at all, these factors differ from other types of mental illness stigma. The goal of this review is to take stock of the literature on SUD stigma, providing a clear set of foundational principles and a blueprint for future research and translational activity.

HIV-related Stigma and Discrimination in Health Care and Health-related Quality of Life among People Living with HIV in England and Wales: A Latent Class Analysis

Though life expectancy of people living with HIV (PLHIV) is now comparable to that of HIV-negative persons, their health-related quality of life (HRQoL) lags behind. Lower HRQoL among PLHIV may vary meaningfully, shaped in part by social factors, including stigma. Using data from Positive Voices, a national cross-sectional probability survey of adults ≥ 18 years living with HIV and accessing HIV care services in England and Wales (N = 4,422), we conducted latent class analysis on responses to a HRQoL measure (problems with mobility, usual activities, self-care, pain/discomfort, anxiety/depression) to identify HRQoL patterns, followed by multinomial logistic regression to examine relationships between HRQoL classes and a 4-item measure of HIV-related stigma and discrimination in health care. Four classes emerged: All Problems (18% prevalence); Pain and Distress (18%); Pain and Mobility (9%); No Problems (55%). Scale scores of HIV-related stigma and discrimination in health care were positively, significantly associated with membership in the All Problems (adjusted odds ratio [aOR] = 2.05; 95% confidence interval [CI] = 1.85, 2.28), Pain and Distress (aOR = 1.56; CI = 1.41, 1.73), and Pain and Mobility classes (aOR = 1.33; CI = 1.16, 1.52) compared to the No Problems class. A similar trend was observed for individual stigma and discrimination items. HRQoL among PLHIV in England and Wales varies and may be underpinned or exacerbated by HIV-related stigma and discrimination in health care. Ensuring stigma-mitigation interventions reach all health care systems/providers and emotional support services reach all PLHIV may improve HRQoL for PLHIV.

Intersectional Discrimination in HIV Healthcare Settings Among Persons with Diagnosed HIV in the United States, Medical Monitoring Project, 2018-2019

Experiences with stigma and discrimination in healthcare settings are associated with negative health outcome for persons with HIV (PWH). PWH may experience discrimination due to the intersection of multiple marginalized social identities. Describing these experiences is important for informing interventions and strategies to reduce stigma and discrimination. We report experiences with discrimination in HIV healthcare settings attributed to multiple characteristics, e.g., sexual orientation, race/ethnicity, income, or social class, and/or injection drug use, among a nationally representative sample of persons with diagnosed HIV in the United States using data from the Medical Monitoring Project (MMP). We calculated weighted prevalences and associated 95% confidence intervals for any discrimination and discrimination attributed to multiple characteristics (intersectional discrimination). Among those experiencing discrimination, nearly 1 in 4 persons reported intersectional discrimination, with a higher burden among key populations of focus for HIV prevention and treatment. Discrimination was attributed to HIV status (62.5%), sexual orientation (60.4%), and race/ethnicity (54.3%). Persons who experienced intersectional discrimination were less likely to have a regular HIV care provider, have trust in HIV care or treatment information from healthcare providers, and be antiretroviral treatment or HIV care visit adherent. Future studies should explore methods to operationalize and assess experiences with intersectional stigma and discrimination and use the outcomes to inform qualitative research that provides more context and a deeper understanding of experiences with intersectional discrimination among PWH.

Prevalence and predictors of perceived COVID-19 stigma within a population-based sample of adults with COVID-19

BACKGROUND

Growing evidence suggests that individuals with COVID-19 face stigmatization, which is associated with poor health outcomes and behaviors. However, very few population-based studies have examined risk factors for experiencing COVID-19 stigma. This study examined prevalence and predictors of perceived COVID-19 stigma using a population-based probability sample of adults with COVID-19.

METHODS

We included adults with polymerase chain reaction-confirmed SARS-CoV-2 in Michigan between January 1, 2020 and July 31, 2021. Perceived COVID-19 stigma was considered present if a respondent answered affirmatively to any of the following items due to people thinking they might have COVID-19: "you were treated badly," "people acted as if they were scared of you," and "you were threatened or harassed." We conducted modified Poisson regression with robust standard errors to estimate associations between perceived COVID-19 stigma and potential predictors, including sex, age, race and ethnicity, household income, education, employment, smoking status, body mass index, preexisting diagnosed physical or mental comorbidities, and COVID-19 illness severity.

RESULTS

Perceived COVID-19 stigma was commonly reported among our respondents (38.8%, n = 2,759). Compared to those over 65 years, respondents who were 18 - 34 (adjusted prevalence ratio (aPR): 1.41, 95% confidence intervals (CI): 1.12 - 1.77) and 35 - 44 years old (aPR: 1.66, 95% CI: 1.31 - 2.09) reported higher perceived stigma. Female respondents had 1.23 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.10 - 1.37) than male respondents and non-Hispanic Black respondents had 1.22 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.04 - 1.44) than non-Hispanic White respondents. Moreover, respondents with pre-existing diagnosed psychological or psychiatric comorbidities were more likely to report perceived COVID-19 stigma (aPR: 1.29, 95% CI: 1.13 - 1.48) compared to those without diagnosed comorbidities. Respondents with very severe COVID-19 symptoms were also more likely to report perceived COVID-19 stigma (aPR: 1.47, 95% CI: 1.23 - 1.75) than those with asymptomatic or mild symptoms.

CONCLUSIONS

We found that populations who are marginalized in United States, such as females, non-Hispanic Black adults, or individuals with chronic conditions, are more likely to report perceived COVID-19 stigma. Continuing to monitor COVID-19 stigma, especially in vulnerable populations, may provide useful insights for anti-stigma campaigns and future pandemics.

Resisting and disrupting HIV-related stigma: a photovoice study

BACKGROUND

The stigma associated with human immunodeficiency virus (HIV) is a significant global public health concern. Health care providers and policy makers continue to struggle with understanding and implementing strategies to reduce HIV-related stigma in particular contexts and at the intersections of additional oppressions. Perspectives and direction from people living with HIV are imperative.

METHODS

In this project we amplified the voices of people living with HIV about their experiences of HIV-related stigma in Manitoba, Canada. We used an arts-based qualitative case study research design using photovoice and narrative interviews. Adults living with HIV participated by taking pictures that represented their stigma experiences. The photos were a catalyst for conversations about HIV and stigma during follow-up individual narrative interviews. Journaling provided opportunities for participants to reflect on their experiences of, and resistance to, stigma. Interviews were audio recorded and transcribed. Photos, journals, and transcribed interviews were analyzed using inductive qualitative methods RESULTS: Through pictures and dialogue, participants (N = 11; 64% women) expressed the emotional and social impacts of stigmas that were created and supported by oppressive structures and interpersonal attitudes and behaviours. These experiences were compounded by intersecting forms of oppression including racism, sexism, and homophobia. Participants also relayed stories of their personal strategies and transitions toward confronting stigma. Strategies were themed as caring for oneself, caring for children and pets, reconstituting social support networks, and resisting and disrupting stigma. Participants made important recommendations for system and policy change.

CONCLUSIONS

These stories of oppression and resistance can inspire action to reduce HIV-related stigma. People living with HIV can consider the strategies to confront stigma that were shared in these stories. Health care providers and policy makers can take concerted actions to support peoples' transitions to resisting stigmas. They can facilitate supportive and anti-oppressive health and social service systems that address medical care as well as basic needs for food, shelter, income, and positive social and community connections.

Typologies of interactions between abortion seekers and healthcare workers in Australia: a qualitative study exploring the impact of stigma on quality of care

BACKGROUND

Abortion stigma involves the stereotyping of, discrimination against, and delegitimization of those who seek and provide abortion. Experiences of abortion care are shaped by stigma at the meso (e.g., lack of local providers) and macro (e.g., abortion regulations) levels. Yet abortion stigma and quality of care are often examined separately. This study sought to articulate the impact of abortion stigma on quality of care in the context of healthcare interactions. It did so by characterizing the features of stigmatizing and non-stigmatizing care in the context of macro-level stigma and other structural factors that influence abortion-seeking experiences, including the coronavirus pandemic's influence on the health system.

METHODS

This qualitative study comprised in-depth interviews with people who sought abortion across Australia between March 2020 and November 2022, recruited through social media and flyers in clinics. Thematic analysis drew on concepts of micro, meso, and macro stigma and person-centered care. We developed typologies of the interactions between abortion seekers and healthcare workers by analytically grouping together negative and positive experiences to characterize features of stigmatizing and and non-stigmatizing care in the context of macro-level influences.

RESULTS

We interviewed 24 abortion seekers and developed five typologies of stigmatizing care: creating barriers; judging; ignoring emotional and information needs; making assumptions; and minimizing interactions. There are five corresponding positive typologies. Macro-level factors, from abortion regulations to rural and pandemic-related health system pressures, contributed to poor experiences in care.

CONCLUSIONS

The positive experiences in this study illustrate how a lack of stigma enables patient-centered care. The negative experiences reflect the interrelationship between stigmatizing beliefs among healthcare workers, macro-level (policy and regulatory) abortion stigma, and structural health service limitations exacerbated during the pandemic. Interventions are needed to reduce stigmatizing interactions between abortion seekers and healthcare workers, and should also consider macro-level factors that influence the behaviors of healthcare workers and experiences of abortion seekers. Without addressing stigma at multiple levels, equitable access to high-quality abortion care will be difficult to achieve. Efforts to integrate stigma reduction into quality improvement have relevance for maternal and reproductive health services globally.

Disability and other identities?-how do they intersect?

This paper addresses intersectionality and disability in global contexts. Disability as a category of identity is often omitted in rhetoric about intersectionality, which usually considers race and gender, with some consideration of other identities. However, disability like other identities is socially constructed, and liable to misrepresentation and is often siloed from other issues and experiences. Someone identifying as disabled may not be recognised by those around them as having other identities too. In discussions about intersectionality, a simplistic "additive" approach is common, while the shifting complexities and interactions between people's multiple identities are not considered with nuance. Disabled people may pragmatically adopt a kind of "strategic essentialism". This allows them to claim a disabled identity and a specific dialogic space in order to gain recognition and perhaps access to support and services. However, they may prefer not to be classified in this dichotomised way because this ignores other aspects of them. Often an impairment is only of importance to the extent that it means that the person needs some reasonable adjustments in order to participate on equal basis with others. Arguably the SDGs and other global guidelines and treaties do not address disability as a significant identity sufficiently, nor recognise it as an important aspect of many people in combination with their other identities, rather than a stand-alone feature of them. When analysing the types of disadvantages that people experience, a broader more flexible approach is needed which recognises the ways in which different identities combine and influence people's experiences.

Transmission of Bias in the Medical Record Among Physical Medicine and Rehabilitation Trainees

ABSTRACT

Stigmatizing language can negatively influence providers' attitudes and care toward patients, but this has not been studied among physiatrists. An online survey was created to assess whether stigmatizing language can impact physical medicine and rehabilitation trainees' attitudes toward patients. We hypothesized stigmatizing language would negatively impact trainees' attitudes. Participants were randomized to a stigmatizing or neutral language vignette describing the same hypothetical spinal cord injury patient. Questions were asked about attitudes and assumptions toward the patient, pain management based on the vignette, and general views regarding individuals with disabilities. Between August 2021 and January 2022, 75 US physical medicine and rehabilitation residency trainees participated. Thirty-seven (49.3%) identified as women; 52 (69.3%) were White, and half (50.6%) received the stigmatized vignette. Participants exposed to stigmatizing language scored 4.8 points lower ( P < 0.01) on the provider attitude toward patient scale compared with those exposed to neutral language. There were no significant differences in the disability attitude scores between the two groups ( P = 0.81). These findings may indicate that stigmatizing language in the medical record may negatively affect physical medicine and rehabilitation trainees' attitudes toward patients. Further exploration is needed to identify the best way to educate trainees and reduce the propagation of bias in the medical record.

Prevalence and Correlates of HIV Disclosure Without Consent Among Women Living With HIV in Metro Vancouver, Canada

This study identified the prevalence and perpetrators of HIV disclosure without consent, and social-structural correlates, among women living with HIV (WLWH). Data were drawn from 7 years (September 14 to August 21) of a longitudinal community-based open cohort of cis and trans WLWH living and/or accessing care in Metro Vancouver, Canada. The study sample included 1871 observations among 299 participants. Overall, 160 (53.3%) women reported lifetime HIV disclosure without consent at baseline, and 115 (38.5%) reported HIV disclosure without consent in the previous 6 months during 7 years of follow-up. In a subanalysis (n = 98), the most common perpetrators of HIV disclosure without consent were friends, people in the community, family, health professionals, and neighbors. In multivariable logistic regression analysis with generalized estimating equations, recent (last 6 months) housing insecurity [adjusted odds ratio (AOR): 1.43, 95% confidence interval: (1.10-1.86)], minoritized sexual identities (LGBQ2S) [AOR: 1.84 (1.22-2.78)], recently being treated, monitored, or diagnosed with depression, anxiety, or post-traumatic stress disorder [AOR: 1.37 (0.98-1.92)], and experiencing physical symptoms related to HIV [AOR: 1.75 (1.25-2.44)] was positively associated with recent disclosure without consent. In a context where HIV nondisclosure before sex is criminalized unless viral load is low and a condom is used, it is concerning that a large proportion of women have experienced HIV disclosure without consent. Laws should focus on protecting rights of WLWH, promoting equity, guaranteeing sexual and reproductive rights, and ensuring access to essential services and privacy. Findings highlight the need for trauma-informed approaches among health and housing services that are responsive to intersections of violence and stigma, and include a focus on confidentiality, autonomy, and safe disclosure practices.

Adolescents' Experiences of Participating in Sensitive Research: A Scoping Review of Qualitative Studies

Despite an increasing emphasis on adolescents' participation rights, there are concerns about their participation in research on sensitive topics, such as trauma and violence. This review reports findings of a scoping review that examined the nature and extent of qualitative studies conducted with adolescents about their experiences of participating in research on sensitive topics. Studies were identified by searching electronic databases and grey literature and reported on qualitative and mixed-methods studies eliciting adolescents' experiences of participating in research on sensitive topics. Seventeen (17) studies were included after screening 4426 records. The scoping review revealed significant adolescent benefits from participation, relating to positive emotions, skill acquisition and enhanced self-efficacy and interpersonal relationships. To a lesser extent, participants also experienced burdens relating to negative emotions, concerns about confidentiality and privacy and inconvenience of participation, which were mitigated by careful attention to research design and researcher engagement and training. Participants shared insights into their motivation to participate, and factors that impacted their experiences of research, such as ethical considerations, including consent procedures, safety and connection in research, study procedures and documentation and researcher characteristics. There were tangible benefits and some burdens involved in adolescents' participation in sensitive research. This review considers implications for research and practice, such as the need to regularly publish findings of consultations, assessing caregiver consent requirements, obtaining adolescent views on study documents and measures and building on existing research, differentiated by age, gender and dis/ability status, especially in diverse and under-represented regions.

[Stigmatization of people living with HIV in health care services in Togo]

Introduction

The elimination of AIDS as a threat to public health implies comprehensive care for those tested in all health facilities and without discrimination/stigmatization. The aim of this study is to evaluate the problems of stigmatization and discrimination of people living with HIV (PLHIV) in health care facilities and their implications for access to care for PLHIV.

Methodology

This is a descriptive cross-sectional study in the 6 health regions of Togo targeting people aged 18 years and over, living with HIV. A hybrid sampling method combining a limited chain referral and a sampling based on the mapping of meeting places/activities was used. Data were collected using the digitized version 2.0 of the PLHIV Stigma Index questionnaire.

Results

A total of 1 119 PLHIV with a mean age of 39 years were included. The sex-ratio was 0.5, and 43.4% had known their HIV status for 1 to 4 years. In the last 12 months, the experiences of stigmatization reported by the PLHIV from health personnel were: gossip (13%), disclosure of status without consent (10%) or avoidance of physical contact (2.6%). In terms of reproductive health, 2.1% of respondents had been advised not to become fathers/mothers and 1.4% had their access to antiretroviral drugs (ARV) conditioned by the use of a contraceptive method. 28.4% of those on ARV had missed one dose of treatment in the last 12 months for fear that someone would find out they were HIV positive. Also, 39.5% of the respondents who were not on ARV justified this by the fear that health workers would treat them badly or reveal their HIV status without their consent.

Conclusion

In health care settings, this phenomenon of HIV-related stigma is multifaceted and deserves to be documented so that it can be taken into account in order to improve the quality of services offered to beneficiary populations.

Diverse policy maker perspectives on the mental health of pregnant and parenting adolescent girls in Kenya: Considerations for comprehensive, adolescent-centered policies and programs

The pregnancy rate in Kenya among adolescent girls is among the highest in the world. Adolescent girls experience increased risk of anxiety and depression during pregnancy and postpartum which can result in poor health outcomes for both mother and baby, and negatively influence their life course. Mental health is often given low priority in health policy planning, particularly in Sub-Saharan Africa (SSA). There is an urgent need to address the treatment gap and provide timely mental health promotion and preventative services, there is a need to focus on the shifting demographic of SSA-the young people. To understand perspectives on policymakers on the mental health prevention and promotion needs of pregnant and parenting adolescent girls, we carried out a series of interviews as part of UNICEF funded helping pregnant and parenting adolescents thrive project in Kenya. We interviewed 13 diverse health and social policy makers in Kenya to understand their perspectives on the mental health experiences of pregnant and parenting adolescent girls and their ideas for optimizing mental health promotion. Six principal themes emerged including the mental health situation for adolescent girls, risk factors for poor mental health and barriers to accessing services for adolescent girls, health seeking behavior effect on maternal and child health outcomes, mental health promotion, protective factors for good mental health, and policy level issues. Examination of existing policies is required to determine how they can fully and effectively be implemented to support the mental health of pregnant and parenting adolescent girls.

Rapid start antiretroviral therapies for improved engagement in HIV care: implementation science evaluation protocol

BACKGROUND

In 2020, the Health Resources and Services Administration's HIV/AIDS Bureau funded an initiative to promote implementation of rapid antiretroviral therapy initiation in 14 HIV treatment settings across the U.S. The goal of this initiative is to accelerate uptake of this evidence-based strategy and provide an implementation blueprint for other HIV care settings to reduce the time from HIV diagnosis to entry into care, for re-engagement in care for those out of care, initiation of treatment, and viral suppression. As part of the effort, an evaluation and technical assistance provider (ETAP) was funded to study implementation of the model in the 14 implementation sites.

METHOD

The ETAP has used implementation science methods framed by the Dynamic Capabilities Model integrated with the Conceptual Model of Implementation Research to develop a Hybrid Type II, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, and HIV-related health outcomes for patients.

DISCUSSION

This approach will allow us to understand in detail the processes that sites to implement and integrate rapid initiation of antiretroviral therapy as standard of care as a means of achieving equity in HIV care.

The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023

In the past decade, the Philippines has gained notoriety as the country with the fastest-growing human immunodeficiency virus (HIV) epidemic in the Western Pacific region. While the overall trends of HIV incidence and acquired immunodeficiency syndrome (AIDS)-related deaths are declining globally, an increase in new cases was reported to the HIV/AIDS and ART Registry of the Philippines. From 2012 to 2023, there was a 411% increase in daily incidence. Late presentation in care remains a concern, with 29% of new confirmed HIV cases in January 2023 having clinical manifestations of advanced HIV disease at the time of diagnosis. Men having sex with men (MSM) are disproportionately affected. Various steps have been taken to address the HIV epidemic in the country. The Philippine HIV and AIDS Policy Act of 2018 (Republic Act 11166) expanded access to HIV testing and treatment. HIV testing now allows for the screening of minors 15-17 years old without parental consent. Community-based organizations have been instrumental in expanding HIV screening to include self-testing and community-based screening. The Philippines moved from centralized HIV diagnosis confirmation by Western blot to a decentralized rapid HIV diagnostic algorithm (rHIVda). Dolutegravir-based antiretroviral therapy is now the first line. Pre-exposure prophylaxis in the form of emtricitabine-tenofovir disoproxil fumarate has been rolled out. The number of treatment hubs and primary HIV care facilities continues to increase. Despite these efforts, barriers to ending the HIV epidemic remain, including continued stigma, limited harm reduction services for people who inject drugs, sociocultural factors, and political deterrents. HIV RNA quantification and drug resistance testing are not routinely performed due to associated costs. The high burden of tuberculosis and hepatitis B virus co-infection complicate HIV management. CRF_01AE is now the predominant subtype, which has been associated with poorer clinical outcomes and faster CD4 T-cell decline. The HIV epidemic in the Philippines requires a multisectoral approach and calls for sustained political commitment, community involvement, and continued collaboration among various stakeholders. In this article, we outline the current progress and challenges in curbing the HIV epidemic in the Philippines.

Correlates of Internalized HIV Stigma: A Comprehensive Systematic Review

Internalized HIV stigma is prevalent and research on internalized HIV stigma has increased during the past 10 years. The aim of this systematic review was to synthesize research on internalized HIV stigma and relationships with various health-related variables in order to better inform the development of interventions aimed at reducing internalized HIV stigma. We reviewed 176 studies with a quantitative design reporting correlates that were peer-reviewed, published in English before January 2021, drawn from PubMed, PSYCHINFO, Web of Science, EBSCO, and Scopus. Synthesis showed consistent associations between internalized stigma and negative psychological (e.g., depression, anxiety), social (e.g., lack of social support, discrimination, nondisclosure, and intersecting stigmas), and health (e.g., substance use, treatment nonadherence, negative clinical HIV outcomes) variables. We argue for a more socioecological approach to internalized stigma, with greater attention for intersectional stigmas, and more longitudinal research, if we are to effectively develop interventions that reduce internalized stigma.

M. SP, Ku HC, Wu YL, Ko NY. Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

Death by suicide is a major public health problem. People living with human immunodeficiency virus (PLHIV) have higher risk of suicidal behavior than the general population. The aim of this review is to summarize suicidal behavior, associated risk factors, and risk populations among PLHIV. Research studies in six databases from January 1, 1988, to July 8, 2021, were searched using keywords that included "HIV," "suicide," and "risk factors." The study design, suicide measurement techniques, risk factors, and study findings were extracted. A total of 193 studies were included. We found that the Americas, Europe, and Asia have the highest rates of suicidal behavior. Suicide risk factors include demographic factors, mental illness, and physiological, psychological, and social support. Depression is the most common risk factor for PLHIV, with suicidal ideation and attempt risk. Drug overdosage is the main cause of suicide death. In conclusion, the current study found that PLHIV had experienced a high level of suicidal status. This review provides an overview of suicidal behavior and its risk factors in PLHIV with the goal of better managing these factors and thus preventing death due to suicide.

Coping with loneliness and stigma associated with HIV in a resource-limited setting, making a case for mental health interventions; a sequential mixed methods study

BACKGROUND

Challenges such as stigma and loneliness may increase vulnerability to Human Immunodeficiency Virus (HIV) infection and negatively affect the quality of life of people living with HIV (PLHIV) despite the massive investment in access to antiretroviral therapy. This study aims to determine the level of loneliness and stigma and explore the coping resources employed by PLHIV in a resource-constrained setting.

METHODS

This was a sequential mixed methods study conducted at the Cape Coast Teaching Hospital (CCTH) in Ghana between May and December 2021. A total of 395 adults were selected using a simple random sampling technique. HIV Stigma Scale and UCLA Loneliness Scale were used to collect quantitative data. A purposive sampling technique was applied to recruit 18 participants to saturation using a semi-structured interview guide. SPSS version 21 was used for the statistical analysis of the quantitative data. HIV-related loneliness and stigma levels were estimated, and bivariate and multivariable logistic regression were used to evaluate associated factors using a statistical significance of p-value (p < .05). In general, the thematic analysis approach by Braun and Clark was employed to analyse the qualitative data. Findings were then triangulated.

RESULTS

The mean age was 46.79 years (± 12.53), 75.4% of the participants were female, with a prevalence of stigma of 99.0% (95%CI = 97.4-99.7) and loneliness of 30.1% (95%CI = 25.6-34.9). Tertiary-level education and instrumental support were associated with lower levels of loneliness. In contrast, comorbidity, personalised stigma, negative self-image, and self-blame were positively related to loneliness. Thematic analyses of the qualitative data produced a range of themes that showed that people living with HIV rely on personal resources, social support networks, and behaviour modification strategies to manage their condition. In particular, some of these strategies include; religiosity and spirituality, family and friends, medication and professional support systems.

CONCLUSION

The results suggest that PLHIV in the developing world face enormous challenges, socially, psychologically and financially. Although there have been global efforts to make HIV services accessible, the findings suggest a need for integrating mental health services contextually to reduce loneliness and HIV-related stigma to improve quality of life.

Perceived public stigma and perceived public exposure by persons living with bipolar disorder: A qualitative study

BACKGROUND

Stigma impact the lives of persons living with bipolar disorder.

AIM

The aim of this study was to explore how perceived public stigma is described by people living with bipolar disorder and examine the links between perceived public stigma and perceived public exposure.

METHOD

Face-to-face in-depth interviews were conducted in a purposive sample of euthymic people living with bipolar disorder recruited in a mood disorder ambulatory unit.

RESULTS

Thematic analysis of the transcript yielded five independent themes that were related to perceived public stigma. Perceived public stigma of bipolar disorder was modeled as comprising the three elements of public stigmas (stereotype, prejudice, and discrimination), with the addition of public exposure as a core component.

CONCLUSION

The representation of bipolar disorder in society via newspapers, films/TV series, conferences, and celebrity self-disclosures is considered to have multiple impacts. People living with bipolar disorder have also reported a perceived public stigma of bipolar disorder that has both specific features and characteristics of general mental illness.

Intersectional stigma and coping strategies of single mothers living with HIV in Thailand

Stigma and discrimination are barriers to the prevention and treatment of HIV, and have serious biomedical, psycho-social and socio-cultural consequences, especially for marginalised groups such as sex workers, transgender people and sexual minorities. There has been little research to date on single mothers living with HIV to situate the stigma they experience within the context of gender, class, ethnicity and other intersecting social inequalities. Drawing on participant observation and in-depth interviews with 28 single mothers living with HIV in Thailand in 2020-21, this article finds that single mothers living with HIV experience intersectional stigma based on their class, ethnicity, religious status and gender, which manifests at the self, family, community and societal levels. In response to this stigmatisation, single mothers have developed four different coping strategies: self-presentation, identity talk, self-exclusion (through distancing and selective association), and empowerment. Findings from the research indicate that an intersectional approach is needed if academics, health workers, policy makers - and even the individuals concerned - are to understand and respond effectively to the HIV-related stigma experienced by specific socio-demographic groups.

Correlates of Intersectional HIV and Substance Use Stigma Affecting People with HIV and Substance Use in St. Petersburg, Russia

People with HIV (PWH) who inject drugs often experience coexisting HIV- and substance use-related stigma manifestations. We assessed correlates of HIV stigma (Berger HIV stigma scale), substance use stigma (Substance Abuse Self-stigma scale) and intersectional HIV and substance use stigma in a cohort of PWH with a lifetime history of drug use in St. Petersburg, Russia. Intersectional stigma was defined as having a score greater than the median for both forms of stigma. Of the 208 participants, 56 (27%) had intersectional stigma. Depressive symptoms and alcohol dependence were significantly associated with a higher HIV and substance stigma score, but not with intersectional stigma. Individual and community interventions to reduce the impact of HIV stigma and substance use stigma affecting PWH who inject drugs should consider assessing and addressing mental health and unhealthy substance use. Further work with longitudinal data is needed to understand mechanisms leading to intersectional stigma.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative

PURPOSE

We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs.

METHODS

We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data.

RESULTS

Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients.

CONCLUSIONS

OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

Relationship between intersectionality and cancer inequalities: a scoping review protocol

INTRODUCTION

Persistent inequalities in cancer care and cancer outcomes exist within and between countries. However, the evidence pertaining to the root causes driving cancer inequalities is mixed. This may be explained by the inadequate attention paid to experiences of patients with cancer living at the intersection of multiple social categories (eg, social class, ethnicity). This is supported by the intersectionality framework. This framework offers an alternative lens through which to analyse and understand how these interlocking systems of oppression uniquely shape the experiences of patients with cancer and drive inequalities. In this protocol, we outline a scoping review that will systematically map what is known about the relationship between intersectionality and inequalities in care experience and cancer outcomes of patients with cancer; and to determine how the intersectionality framework has been applied in studies across the cancer care pathway and across countries.

METHODS AND ANALYSIS

This study will be guided by Arksey and O'Malley's, and Levac et al's frameworks for scoping reviews. We will identify and map the evidence on cancer inequalities and intersectionality from 1989 to present date. Electronic databases (EMBASE, PsychINFO, CINAHL, Medline, Web of Science, ProQuest) and a systematic search strategy using a combination of keywords and Boolean operators AND/OR will be used to identify relevant studies. Screening of eligible papers and data extraction will be conducted by two independent reviewers, and disagreements resolved by discussion with the research team. We will use an iterative process to data charting using a piloted form. Findings will be collated into a narrative report.

ETHICS AND DISSEMINATION

Ethical approval is not required since data used are from publicly available secondary sources. Findings will be disseminated through peer-reviewed journals, conferences and stakeholder meetings. Further, findings will inform the next phases of a multistage research project aimed at understanding inequalities among patients with breast cancer.

Individual-, Interpersonal- and Institutional-Level Factors Associated with HIV Stigma Among Youth in Kenya

HIV stigma remains a barrier in achieving optimal HIV treatment. We studied the prevalence and predictors of HIV stigma among adolescents and youth with HIV (AYWHIV) ages 15-24 years in Western Kenya. Of 1011 AYWHIV, 69% were female with a median age of 18 years. Most (59%) attended adolescent clinic days, and 40% attended support groups. One-quarter (27%) had experienced physical, 18% emotional, and 7% sexual violence. The majority of AYWHIV (88%) reported disclosure concerns, 48% reported perceived community stigma, 36% experienced, and 24% internalized stigma. Compared to AYWHIV attending adolescent clinics, those in general/adult clinics had higher internalized stigma. Similarly, having dropped out of school was associated with higher internalized stigma. AYWHIV in sexual relationships had higher experienced stigma and disclosure concerns. Lastly, exposure to violence was associated with higher experienced, internalized, perceived community stigma and disclosure concerns. These risk factors can be targeted when developing stigma-prevention interventions.

The impacts of COVID-19 pandemic on service delivery and treatment outcomes in people living with HIV: a systematic review

INTRODUCTION

The COVID-19 epidemic and various control and mitigation measures to combat the widespread outbreak of the disease may affect other parts of health care systems. There is a concern that the COVID-19 pandemic could disrupt HIV services. Therefore, this study aimed to systematically evaluate the effect of the COVID-19 pandemic on service delivery and treatment outcomes in people with HIV.

METHODS

In this study, a systematic search was conducted using the keywords in the online databases including Scopus, PubMed, Web of Science, and Cochrane databases. The retrieved articles underwent a two-step title/abstract and full-text review process, and the eligible papers were selected and included in the qualitative synthesis.

RESULT

We selected 16 studies out of 529 retrieved records that met the inclusion criteria for this review. Study populations of the selected studies were either HIV-positive patients or HIV clinics and healthcare providers. Most studies were focused on adhering to and obtaining medication and attending clinical appointments and their decrement during the pandemic. Other aspects of HIV care (alternative healthcare settings, viral suppression, psychological care, etc.) were discussed to a lesser extent by the included studies.

CONCLUSION

Interruption in in-person visits and medical follow-up services, loss of adherence to treatment, and subsequent increase in mortality due to the COVID-19 pandemic complications in PLHIV have led to growing concerns. Other challenges were psychological disorders such as anxiety and depression, an increase in substance abuse, and a rise in experienced stigma and discrimination. However, the use of telemedicine in some countries helps to alleviate the situation to some extent and is recommended in similar settings in the future.

Stigma mastery in people living with HIV: gender similarities and theory

Aims

This study aimed to determine the prevalence of, factors associated with, and to build a theoretical framework for understanding Internalsed HIV-related Stigma Mastery (IHSM).

Methods

A cross-sectional study nested within a 2014 Stigma Reduction Cohort in Uganda was used. The PLHIV Stigma Index version 2008, was used to collect data from a random sample of 666 people living with HIV (PLHIV) stratified by gender and age. SPSS24 with Amos27 softwares were used to build a sequential-mediation model.

Results

The majority of participants were women (65%), aged ≥ 40 years (57%). Overall, IHSM was 45.5% among PLHIV, that increased with age. Specifically, higher IHSM correlated with men and older women "masculine identities" self-disclosure of HIV-diagnosis to family, sharing experiences with peers. However, lower IHSM correlated with feminine gender, the experience of social exclusion stress, fear of future rejection, and fear of social intimacy. Thus, IHSM social exclusion with its negative effects and age-related cognition are integrated into a multidimensional IHSM theoretical framework with a good model-to-data fit.

Conclusion

Internalised HIV-related Stigma Mastery is common among men and older women. Specificially, "masculine identities" self-disclose their own HIV-positive diagnosis to their family, share experiences with peers to create good relationships for actualising or empowerment in stigma mastery. However, social exclusion exacerbates series of negative effects that finally undermine stigma mastery by young feminine identities. Thus, stigma mastery is best explained by an integrated empowerment framework, that has implications for future practice, policy, and stigma-related research that we discuss.

The Pervasive Impact of the Stigmatization of Gastrointestinal Diseases-A Patient's Perspective

Stigma is a centuries-old phenomenon that pervades chronic digestive diseases, regardless of classification. Patients with gastrointestinal (GI) illness perceive others hold stigmatizing beliefs about them and their illness, including from medical professionals, and may go on to internalize or believe these negative stereotypes as true. These perceptions seem to be based on the thought that the public views GI diseases negatively. The effects of GI stigma are substantial and influence quality of life, psychological distress, treatment adherence, disease severity, and health-care utilization. These realities underscore the need for stigma to be addressed by the GI community and measures taken to mitigate its impacts.

HIV-related challenges and women's self-response: A qualitative study with women living with HIV in Indonesia

HIV infection is a major public health concern, with a range of negative impacts on People Living with HIV (PLHIV). A qualitative study in Yogyakarta, Indonesia, using in-depth interviews with 26 Women Living with HIV (WLHIV) was conducted to understand HIV risk factors and impact and their access to HIV care services. This paper describes the self-response of WLHIV towards negative HIV-related experiences facing them and adds to the existing literature which tends to focus on HIV impact only, as opposed to strategies that many WLHIV have used to empower and educate themselves and their family/community. Participants were recruited using the snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. Our study highlighted that WLHIV experienced psychological challenges, stigma and discrimination. However, they demonstrated remarkable self-response and capacity in pursuing effective strategies and support to protect themselves, and educating themselves and others around them to rebuild trust and regain respect and acceptance. Our findings indicate that the needs of WLHIV should be addressed through policy and practice to help them cope with HIV-related psychological and social challenges effectively. Family and community members seem to play an important role in those negative challenges against WLHIV, thus there is also a need for HIV education programs for family and community members to enhance their HIV-health literacy and acceptance of PLHIV.

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.

Suicidality Among People Living With HIV From 2010 to 2021: A Systematic Review and a Meta-regression

OBJECTIVE

The association between human immunodeficiency virus (HIV)/AIDS and suicidality is not well understood, partly because of variability in results. This meta-analysis aimed to investigate the predictive value of HIV/acquired immune deficiency syndrome for incident suicidality.

METHODS

A literature review was conducted of articles published between January 1, 2010, and October 31, 2021. The following databases were searched: Embase, MEDLINE, CINAHL, Web of Science, and Scopus. The search terms included human immunodeficiency virus (HIV), suicidal behavior, auto mutilation, and self-injurious behavior. Observational studies were screened following a registered protocol, and eligible ones were meta-analyzed and followed by meta-regression.

RESULTS

A total of 43 studies were included in this systematic review, and a meta-regression included 170,234 participants. The pooled prevalence estimates of suicidal ideation, attempted suicide, and deaths by suicide were 22.3%, 9.6%, and 1.7%, respectively. The following significant risk factors for suicide ideation were found: substance use, depression, low quality of life, low social support, without HIV status disclosure, living alone, low level of memory problems, family history of suicide, and stage III of HIV. Risk factors for suicide attempts were depression and family history of suicide. An elevated risk for suicide-related death was found for people living with HIV (PLHIV) who had a psychiatric disorder and in studies conducted in hospital-based settings (versus national database studies or HIV clinic settings).

CONCLUSIONS

The risk of suicidality is high among PLHIV within all six World Health Organization regions during the modern antiretroviral therapy era. Assessment of socioeconomic and psychological factors is recommended for further management to prevent suicide among PLHIV. The present findings are useful for design of intervention protocols and development of clinical practice guidelines intended to manage the well-being of PLHIV worldwide.

'Maybe I Shouldn't Talk': The Role of Power in the Telling of Mental Health Recovery Stories

Mental health 'recovery narratives' are increasingly used within teaching, learning and practice environments. The mainstreaming of their use has been critiqued by scholars and activists as a co-option of lived experience for organisational purposes. But how people report their experiences of telling their stories has not been investigated at scale. We present accounts from 71 people with lived experience of multiple inequalities of telling their stories in formal and informal settings. A reflexive thematic analysis was conducted within a critical constructivist approach. Our overarching finding was that questions of power were central to all accounts. Four themes were identified: (1) Challenging the status quo; (2) Risky consequences; (3) Producing 'acceptable' stories; (4) Untellable stories. We discuss how the concept of narrative power foregrounds inequalities in settings within which recovery stories are invited and co-constructed, and conclude that power imbalances complicate the seemingly benign act of telling stories of lived experience.

Impact of Asymptomatic Neurosyphilis on Patients Quality of Life and Social Stigma

Background/Objectives

Neurosyphilis is a disease caused by Treponema pallidum when it invades the central nervous system. Asymptomatic neurosyphilis (ANS) is one of the most common types of neurosyphilis, however it is often misdiagnosed. This study aimed to explore the impact of ANS on patient's quality of life and social stigma.

Methods

A total of 159 ANS patients were diagnosed by their serology and cerebrospinal fluid. These patients' stigma and quality of life were assessed separately through the Social Impact Scale (SIS) and the Easy Response Questionnaire.

Results

The average age was 36.25±8.36 years old, and 114 patients were males (71.69%). The serum syphilis test of 159 selected patients was positive, and the indicators of nucleus cells, protein quantification, and syphilis antibodies in the cerebrospinal fluid met the criteria for ANS. The total stigma score was (40.23 ±10.12), with the scores of the different entries being clearly differentiated, with the highest being the 15th entry (I feel I need to keep my illness a secret), with an average score of 3.15/4.

Conclusion

Patients with asymptomatic neurosyphilis may feel social stigma and are more negative when facing their disease. Health-care workers should be aware of the particular aspects of their condition and pay special attention to the need for patient privacy.

Gay Community Stress Scale with Its Cultural Translation and Adaptions in Taiwan

The present study aimed to adapt the Gay Community Stress Scale (GCSS) into the traditional Chinese version for measuring gay community stress experienced. Additionally, we examined its psychometric propensities among gay and bisexual men (GBM) in Taiwan. In total, 736 GBM participated in this study and completed the 35-item traditional Chinese version of the GCSS (29 items from the original GCSS and six items from the results of the focus group interviews among GBM in Taiwan); the Measure of Internalized Sexual Stigma for Lesbians and Gay Men (MISS-LG); the State-Trait Anxiety Inventory (STAI); and the Center for Epidemiological Studies Depression Scale (CES-D). Exploratory factor analysis results suggest a five-factor structure (i.e., Sex, Status, Competition, Exclusion, and Externals) for the 32-item traditional Chinese version of the GCSS among Taiwanese GBM; three items were deleted due to low factor loadings (i.e., <0.3). The five-factor "Externals" were not observed in the original GCSS. Moreover, the concurrent validity of the traditional Chinese version was supported by the positive correlations with MISS-LG, STAI, and CES-D. In conclusion, the traditional Chinese version of the GCSS showed relatively satisfactory psychometric properties. However, further research is needed to investigate the reasons for the possible etiology account for the different factor structures between the traditional Chinese version and the original GCSS.