Discrimination against HIV-infected people and the spread of HIV: some evidence from France

Analysis of Participant Stigma and Associated Costs of a Peer-Led Social Media HIV Intervention

HIV-related stigma is a primary barrier to seeking HIV care. Online social media interventions utilizing peer-led approaches provide an opportunity to revolutionize HIV health behavior change. Secondary analysis of the UCLA HOPE Study (6 waves) was done to examine the effectiveness of an online peer-led intervention in reducing HIV-related internalized stigma (IS), association between IS and sexual risk behaviors (SRB), and associated costs for changing the likelihood of HIV testing. Among 897 participants, an inverse relationship between IS (Discomfort with people with HIV, Stereotypes, Moral Judgment) and SRB (Number of Sexual Partners, Sexual Encounters) factors was identified over time (p < .05). Engagement in stigma conversations increased participant likelihood to request HIV tests (B = 0.02, Wald = 8.10, p = .004) when made in group versus one-on-one contact. Innovative technology has potential to improve HIV-care efforts through expanded reach to at-risk populations, improved communication maintenance, ease of accessibility, and user anonymity.

A qualitative study of injection and sexual risk behavior among unstably housed people who inject drugs in the context of an HIV outbreak in Northeast Massachusetts, 2018

BACKGROUND

To investigate the underlying causes of a sudden increase in HIV among people who inject drugs (PWID) and initiate an appropriate response to the outbreak, we engaged in in-depth qualitative interviews with members of the PWID community in Lawrence and Lowell, Massachusetts.

METHODS

We interviewed 34 PWID who were currently or recently unstably housed, then transcribed interviews and coded transcripts, grouping codes into categories from which we identified key themes.

RESULTS

Participants described a heightened threat of overdose prompting PWID to inject together, increasing opportunities for sharing injection equipment. There were misunderstandings about safe injection practices to prevent HIV transmission and a low threshold for injection-related risk taking. Stigma regarding HIV prevented conversations about HIV status. Less thought was given to sexual risks than injection-related risks for HIV transmission.

CONCLUSIONS

We found multiple facilitators of HIV transmission. Additional HIV education and prevention interventions focusing on both injection and sexual risk practices would benefit this population, in addition to structural interventions such as increased access and availability of syringe service programs.

Exploring factors associated with HIV secondary stigma among adolescents and young adults in Uganda: A cross-sectional study

HIV stigma is a public health problem. It refers to irrational judgments and attitudes towards people living with or at risk of HIV. Among adolescents and young adults living with HIV, stigma can negatively influence help-seeking decisions and impede HIV prevention efforts. The present study aimed to explore social-ecological factors associated with HIV-related stigma using a cross-sectional study design. Data used were from the 2016 Uganda Demographic and Health Survey [UDHS] of young men (n = 2214) and young women (n = 8058) aged 15-24 years. We conducted a gender disaggregated multivariable logistic regression to understand social-ecological factors associated with HIV secondary stigma. An overwhelming majority of participants (85%) indicated that secondary HIV stigma was associated with factors such as gender, ethnicity, education, wealth, cultural attitudes, and testing experiences. The study concludes that many young people living with HIV experience stigma in Uganda. Therefore, the government of Uganda, health professionals, and researchers should consider developing interventions that address HIV stigma and discrimination. Supportive programmes, such as peer support services and community-based interventions, are needed to help young people living with HIV learn to cope with the illness.

Effects of HIV-Related Discrimination on Psychosocial Syndemics and Sexual Risk Behavior among People Living with HIV

In the context of HIV-related stigma and discrimination, people living with HIV (PLHIV) might be vulnerable to a ‘syndemic’ of co-occurring psychosocial challenges that can affect sexual behavior. The present study examined how HIV-related discrimination contributes to co-occurring psychosocial syndemic problems and results in inconsistent condom use among PLHIV in Hong Kong. Two-hundred and ninety-one PLHIV were recruited to complete a self-report questionnaire. More than one-quarter of the sample experienced two or more psychosocial syndemic problems, and 74.1% of the participants who had sex with steady partners reported inconsistent condom use over the past three months. The results indicated that HIV-related discrimination was positively predictive of the number of psychosocial syndemic problems. HIV-related discrimination and psychosocial syndemics were associated with increased odds of inconsistent condom use with steady partners (AOR = 5.40 and AOR = 3.09 respectively). Findings from structural equation modeling showed that psychosocial syndemics mediated the effect of HIV-related discrimination on condom use consistency with steady partners. PLHIV in Hong Kong suffered from the syndemic effects of stigma, social isolation, and poor mental health, which rendered them vulnerable to condomless sex. In order to curb the rapidly increasing incidence of HIV, multi-level strategies should be adopted to concurrently address the structural inequities and psychosocial syndemics faced by PLHIV.

Accessibility and availability of assistant reproductive technology for people living with HIV in Europe: a thematic literature review

As antiretroviral therapies have transformed HIV into a manageable chronic disease, many individuals have or will choose to have children, and the use of assisted reproductive technology can serve as an effective risk-reducing strategy. In this thematic literature review, we examine the state of research on access to and availability of assisted reproductive health technologies for people living with HIV in Europe, with the aim of identifying gaps for further research. We find that the existing literature is focused on serodiscordant couples consisting of an HIV-positive man and an HIV-negative women. This is in part because more treatment options are available for men living with HIV than women, reflecting underlying gender discrimination in treatment. The existing scholarship largely ignores reproductive options for seroconcordant couples or single individuals, or for men and women with underlying infertility. Finally, very little research addresses the question of financial affordability, which is a known barrier to infertility treatment.

Renunciation of health care by people living with HIV in France is still associated with discrimination in health-care services and social insecurity - results from the ANRS-VESPA2 survey

BACKGROUND

This study aimed to estimate the frequency of renunciation of health care among people living with HIV (PLHIV) in France, including health care unrelated to HIV, and to characterize associated socioeconomic and psychosocial risk factors.

METHODS

The cross-sectional ANRS-VESPA2 survey was conducted on adult PLHIV attending French hospitals in 2011. Correlates of health-care renunciation in the 12 months before the survey were assessed through logistic modelling.

RESULTS

Among the 3,020 PLHIV included in the sample, 17% declared health-care renunciation during the preceding year and 42% had a high level of social insecurity. During the previous 2 years, 8% and 11%, respectively, were discriminated against by medical staff and family. In multivariate analysis, positive associations were found between health-care renunciation and a high level of social insecurity (adjusted odds ratio [95% CI] 3.44 [2.54, 4.65]; P<0.001), having children (1.52 [1.10, 2.10]; P=0.01), smoking tobacco (1.50 [1.13, 1.98]; P=0.01), discrimination by medical staff (1.53 [1.22, 2.29]; P=0.04) or family (2.48 [1.75, 3.52]; P<0.001), major depressive episodes (1.46 [1.02, 2.09]; P=0.04), past or current drug injection (1.54 [1.03, 2.30]; P=0.04), and younger age (0.98 [0.97, 1.00]; P=0.03). Health-care renunciation was also negatively associated with HIV diagnosis after 1996 (1996-2002: 0.64 [0.46, 0.90]; P=0.01; ≥2003: 0.56 [0.40, 0.77]; P=0.001).

CONCLUSIONS

In spite of universal health insurance in France, barrier- and refusal-renunciation of health care by PLHIV remain frequent. Poor psychosocial outcomes and discrimination by families and health-care providers compound the negative effect of social insecurity on health-care seeking in this population. To ensure optimal medical care, strategies are needed to prevent discrimination against PLHIV in health-care services. Special attention must be provided to patients experiencing social insecurity.

Validation of an HIV/AIDS Stigma Measure for Children Living with HIV and Their Families

BACKGROUND

There are few validated tools to measure stigma, particularly among children living with HIV and their families.

METHODS

This study was nested within a larger study that followed 240 child-caregiver dyads (children aged 10-15 years) at 8 clinics in western Kenya. The stigma instrument was administered to all child-caregiver dyads at 2 time points 6 months apart. The primary end point was to construct validity assessed by comparison to criterion constructs using generalized estimating equation models.

RESULTS

Mean age of child participants was 12.3 years and 52% were female. Generally, caregivers reported experiencing higher levels of HIV stigma compared to their children. Children (9%) and caregivers (14%) reported that HIV stigma made them feel stressed, anxious, and depressed. Child and caregiver stigma items showed high construct validity by emotional and behavioral outcomes.

CONCLUSIONS

The stigma instrument showed high validity when compared to emotional and behavioral outcomes.

Anticipated HIV Stigma and Delays in Regular HIV Testing Behaviors Among Sexually-Active Young Gay, Bisexual, and Other Men Who Have Sex with Men and Transgender Women

Young gay, bisexual and other men who have sex with men (YGBMSM) and young transgender women are disproportionately affected by HIV/AIDS. The success of biomedical prevention strategies is predicated on regular HIV testing; however, there has been limited uptake of testing among YGBMSM and young transgender women. Anticipated HIV stigma-expecting rejection as a result of seroconversion- may serve as a significant barrier to testing. A cross-sectional sample of YGBMSM (n = 719, 95.5%) and young transgender women (n = 33, 4.4%) ages 15-24 were recruited to participate in a one-time survey. Approximately one-third of youth had not tested within the last 6 months. In a multivariable model, anticipated HIV stigma and reporting a non-gay identity were associated with an increased odds of delaying regular HIV testing. Future research and interventions are warranted to address HIV stigma, in order to increase regular HIV testing among YGBMSM and transgender women.

Racial Pride and Condom Use in Post-Incarcerated African-American Men Who Have Sex With Men and Women: Test of a Conceptual Model for the Men in Life Environments Intervention

African-American men who have sex with men and women (MSMW) are among those most heavily impacted by HIV in the United States, and those who have histories of incarceration are at further risk of infection. The Men in Life Environments (MILE) HIV prevention intervention was developed to provide culturally appropriate skills-based education and support for African-American MSMW with recent histories of incarceration. The MILE's conceptual framework was informed by three theories: Theory of Reasoned Action and Planned Behavior, Critical Thinking and Cultural Affirmation Model, and Empowerment Theory. The theory-based framework posits that improving racial pride is crucial in building self-efficacy and intentions that in turn promote health-protective behaviors. Therefore, our study aimed to assess whether baseline associations between racial pride and condom use self-efficacy, intentions, and behaviors among African-American MSMW with histories of incarceration align with our conceptual model. We report data on 212 participants recruited from Los Angeles County Sheriff's Department Men's Central Jail and the local community. Using structural equation modeling, we tested two separate models: one with female sexual partners and one with male sexual partners, while stratifying by participant's HIV status. Only among HIV-negative participants was greater racial pride associated with less condomless intercourse with men. In this group, greater self-efficacy and intentions-but not racial pride-predicted less condomless intercourse with women. Our findings suggest that racial pride is an important factor to address in HIV prevention interventions for post-incarcerated African-American MSMW.

Assessment in the primary care of the State of São Paulo, Brazil: incipient actions in sexual and reproductive health

OBJECTIVE

The objective of this study is to assess performance in sexual and reproductive health of primary health care services of the Brazilian Unified Health System, in the State of São Paulo, Brazil.

METHODS

An evaluative framework was built for sexual and reproductive health with the categorization of 99 indicators in three domains: sexual and reproductive health promotion (25), sexually transmitted infections/AIDS prevention and care (43), and reproductive health care (31). This framework was applied to assess the services responses to the questionnaire of Quality Evaluation of Primary Health Care in the Municipalities of São Paulo State (QualiAB), in 2010. Percentages were calculated for positive responses to indicators and performance in the sexual and reproductive health dimension, according to domains, and their contribution to the overall score in sexual and reproductive health (Friedman), relative participation (Dunn), and correlation (Spearman) was verified.

RESULTS

Overall, 2,735 services participated in the study. They were located in 586 municipalities (distributed throughout the 17 regional health departments of São Paulo), of which 70.6% had fewer than 100,000 inhabitants. The overall average performance of these services for sexual and reproductive health is 56.8%. The actions are characterized by: prenatal with adequate beginning and exams, better organization for immediate rather than for late postnatal care, and selective reproductive planning for some contraceptives; prevention based on specific protection, limitations in the prevention of congenital syphilis, in the treatment of sexually transmitted infections, and in the screening of cervical and breast cancer; specific educational activities, with a restricted vulnerability approach, focus on sexuality over reproduction. The domain of reproductive health has greater participation in the overall score, followed by prevention/care and promotion. The three domains are correlated; the domain of prevention/care has the highest correlation with the other ones.

CONCLUSIONS

The implementation of sexual and reproductive health in primary health care in the services studied is incipient. The revision of the purpose of the work, the dissemination of technologies, and the investing in permanent education are needed. The evaluative framework built can be used by the sexual and reproductive health program services and management in primary health care, thereby contributing to their actions.

OBJETIVO

Avaliar o desempenho em saúde sexual e reprodutiva de serviços de atenção primária à saúde do Sistema Único de Saúde, no estado de São Paulo.

MÉTODOS

Construiu-se quadro avaliativo para a saúde sexual e reprodutiva com a categorização de 99 indicadores em três domínios: promoção à saúde sexual e reprodutiva (25), prevenção e assistência às doenças sexualmente transmissíveis/aids (43), e atenção à saúde reprodutiva (31). Esse quadro foi aplicado para avaliar as respostas dos serviços ao questionário Avaliação da Qualidade da Atenção Básica em Municípios de São Paulo (QualiAB), em 2010. Calcularam-se as porcentagens de respostas positivas aos indicadores e o desempenho na dimensão saúde sexual e reprodutiva, segundo os domínios; e verificou-se sua contribuição para o escore geral em saúde sexual e reprodutiva (Friedman), participação relativa (Dunn) e correlação (Spearman).

RESULTADOS

Participaram 2.735 serviços, localizados em 586 municípios (distribuídos nos 17 departamentos regionais de saúde paulistas), dos quais 70,6% municípios com menos de 100.000 habitantes. A média geral do desempenho desses serviços para saúde sexual e reprodutiva é 56,8%. As ações são caracterizadas por: pré-natal com início e exames adequados, melhor organização para puerpério imediato do que tardio, e planejamento reprodutivo seletivo para alguns contraceptivos; prevenção baseada em proteção específica, limites na prevenção da sífilis congênita, no tratamento de doenças sexualmente transmissíveis, no rastreamento do câncer cervical e mamário; atividades educativas pontuais, com restrita abordagem das vulnerabilidades, predomínio do enfoque da sexualidade centrado na reprodução. O domínio saúde reprodutiva tem maior participação no escore geral, seguido de prevenção/assistência e promoção. Os três domínios estão correlacionados; o domínio prevenção/assistência apresenta as maiores correlações com os demais.

CONCLUSÕES

A implementação da saúde sexual e reprodutiva na atenção primária à saúde nos serviços estudados é incipiente. É necessário rever finalidades do trabalho, disseminar tecnologias e investir em educação permanente. O quadro avaliativo construído pode ser utilizado pelos serviços e pela gestão do programa de saúde sexual e reprodutiva na atenção primária à saúde e contribuir para suas ações.

"HIV Changed My Life Forever": An Illustrative Case of a Sub-Saharan African Migrant Woman Living with HIV in Belgium

Living with HIV and AIDS changes everything for people diagnosed with HIV and it can be the most difficult experience in life. Like most people who have chronic diseases, these individuals have to deal with living a normal and quality life. Globally, more women (51%) than men are HIV positive. The main aim of this paper was to describe a sub-Saharan African migrant woman’s lived experience, and also to use the individual’s story to raise questions about the larger context after a HIV diagnosis. A qualitative study consisting of a personal story of a HIV-infected sub-Saharan African living in Belgium was conducted. Data were analysed using thematic analysis. The main themes that emerged from the data included relational risks, personal transformation and the search for normality, anxiety, depression, fear of stigma, societal gender norms, and support. The participant reported that marriage was no guarantee of staying HIV-free, especially in a male-dominant culture. This case further illustrates that married and unmarried African women are often at high risk of HIV and also informs us how HIV could spread, not only because of cultural practices but also because of individual behaviour and responses to everyday life situations. The participant also emphasized that she is faced with physical and mental health problems that are typical of people living with HIV. The vulnerability of sub-Saharan African women to HIV infection and their precarious health-related environments wherever they happen to be is further elucidated by this case.

PERCEPTIONS OF STIGMA AND DISCRIMINATION IN HEALTH CARE SETTINGS TOWARDS SUB-SAHARAN AFRICAN MIGRANT WOMEN LIVING WITH HIV/AIDS IN BELGIUM: A QUALITATIVE STUDY

Stigma and discrimination within health care settings remain a public health challenge across diverse cultural environments and may have deleterious effects on mental and physical health. This study explores the causes, forms and consequences of HIV-related stigma and discrimination among migrant sub-Saharan African women living with HIV in Belgium. A qualitative study was conducted with 44 HIV-positive sub-Saharan African migrant women between April 2013 and December 2014 in health care settings in Belgium. Data were analysed using thematic content analysis. Twenty-five of the women reported overt stigma and discrimination and fifteen reported witnessing behaviours that they perceived to be stigmatizing and discriminatory in health care settings. The themes that emerged as to the causes of stigma and discrimination were: public perceptions of migrants and HIV, fear of contamination and institutional policies on HIV management. Reported forms of stigma and discrimination included: delayed or denied care, excessive precautions, blame and humiliation. The consequences of stigma and discrimination were: emotional stress, inconsistent health-care-seeking behaviour and non-disclosure to non-HIV treating personnel. Stigma and discrimination in health care settings towards people with HIV, and more specifically towards HIV-positive sub-Saharan African migrant women, impedes sustainable preventive measures. Specialized education and training programmes for non-HIV health care providers require in-depth investigation.

HIV Stigma: Perspectives from Kenyan Child Caregivers and Adolescents Living with HIV

Stigma shapes all aspects of HIV prevention and treatment, yet there are limited data on how HIV-infected youth and their families are affected by stigma in sub-Saharan Africa. The authors conducted a qualitative study using focus group discussions among 39 HIV-infected adolescents receiving care at HIV clinics in western Kenya and 53 caregivers of HIV-infected children. Participants felt that while knowledge and access to treatment were increasing, many community members still held negative and inaccurate views about HIV, including associating it with immorality and believing in transmission by casual interactions. Stigma was closely related to a loss of social and economic support but also included internalized negative feelings about oneself. Participants identified treatment-related impacts of stigma, including nonadherence, nondisclosure of status to child or others, and increased mental health problems. Qualitative inquiry also provided insights into how to measure and reduce stigma among affected individuals and families.

The Men Who Have Sex with Men HIV Care Cascade in Rio de Janeiro, Brazil

Brazil has a concentrated HIV epidemic and men who have sex with men (MSM) are disproportionately affected. Yet, no data is available on the HIV care cascade for this population. This study aimed to assess the HIV care cascade among MSM newly diagnosed through innovative testing strategies in Rio de Janeiro. Data from 793 MSM and travestites/transgender women (transwomen) tested for HIV at a non-governmental LGBT organization and a mobile testing unit located at a gay friendly venue were analyzed. A 12-month-after-HIV-diagnosis-censored cohort was established using CD4, viral load and combination antiretroviral therapy (cART) longitudinal data from those diagnosed with HIV. A cross-sectional HIV care cascade was built using this data. The relative risks of achieving each cascade-stage were estimated using generalized linear models according to age, self-declared skin-color, education, history of sexually transmitted diseases (STD), drug use and prior HIV testing. From Jan-2013 to Jan-2014, 793 MSM and transwomen were tested, 131 (16.5%) were HIV-infected. As of January 2015, 95 (72.5%) were linked to HIV care, 90 (68.7%) were retained in HIV care, 80 (61.1%) were on cART, and 50 (38.2%) were virally suppressed one year after HIV diagnosis. Being non-white (Relative risk [lower bound; upper bound of 95% confidence interval] = 1.709 [1.145; 2.549]) and having a prior HIV-test (1.954 [1.278; 2.986]) were associated with an HIV-positive diagnosis. A higher linkage (2.603 [1.091; 6.211]) and retention in care (4.510 [1.880; 10.822]) were observed among those who were older than 30 years of age. Using community-based testing strategies, we were able to access a high-risk MSM population and a small sample of transwomen. Despite universal care coverage and the test-and-treat policy adopted in Brazil, the MSM cascade of care indicates that strategies to increase linkage to care and prompt cART initiation targeted to these populations are critically needed. Interventions targeting non-white and young MSM should be prioritized.

Stigma against People Living with HIV/AIDS in China: Does the Route of Infection Matter?

In the current study, we tested the hypothesis that people who contracted HIV from “blameless” routes (e.g., blood transfusion, sex with stable partners) are less stigmatized compared to people who contracted HIV from “blamable” routes (e.g., injection drug use, sex with sex workers). A cross-sectional study was conducted among 2,987 participants in Guangxi province, China, between 2012 and 2013. We employed both explanatory and predictive modeling strategy by using multivariate linear regression models. In the explanatory models, we assessed the association between routes of infection and three types of stigma (perceived, internalized, and enacted). From identified routes of infection that significantly contributed to higher stigma, we employed predictive modeling to explore predictors for the specific type of stigma. Multiple-imputation was employed for sensitivity analyses. Of the total sample, 63% were male and the average age was 42.9 years (ranged between 18 and 88). Multivariate regression models revealed that contraction from commercial sex increased the perceived (β = 0.46, 95%CI = 0.02, 0.90) and internalized stigma (β = 0.60, 95%CI = 0.09, 1.10), while injecting drug use increased the perceived (β = 0.65, 95%CI = 0.07, 1.22) and enacted stigma (β = 0.09, 95%CI = 0.02, 0.16) after controlling for confounders. Among PLWHA who were infected via commercial sex partners, social support was negatively associated with perceived (β = -0.47, 95%CI = -0.79, -0.14) and internalized stigma (β = -0.80, 95%CI = -1.24, -0.35). Among PLWHA who were infected via injecting drugs, no adherence to antiretroviral treatment (β = 0.41, 95%CI = 0.01, 0.82) was positively associated with perceived stigma, and disclosure of serostatus to others was negatively associated with enacted stigma (β = -0.20, 95%CI = -0.34, -0.05). Knowledge of the association between routes of infection and stigma can guide health professionals and policy makers to develop tailored intervention strategies to mitigate the effects of stigma and enhance HIV care utilization among PLWHA in China.

Unsafe sexual behaviors among HIV-positive men and women in Honduras: the role of discrimination, condom access, and gender

BACKGROUND

We conducted a study among HIV-positive men and women in Honduras to describe demographics, HIV risk behaviors and sexually transmitted infection prevalence, and identify correlates of unsafe sex.

METHODS

Participants were recruited from HIV clinics and nongovernmental organizations in Tegucigalpa and San Pedro Sula, Honduras in a cross-sectional study in 2006. We used audio-assisted computer interviews on demographics; behaviors in the past 12 months, 6 months, and 30 days; and access to care. Assays performed included herpes (HSV-2 Herpes Select), syphilis (rapid plasma reagin [RPR] and Treponema pallidum particle agglutination assay [TPPA]) serology, and other sexually transmitted infections by polymerase chain reaction (PCR). Bivariate and multivariate analyses were conducted to assess variables associated with unprotected sex across all partner types in the past 12 months.

RESULTS

Of 810 participants, 400 were from Tegucigalpa and 410 from San Pedro Sula; 367 (45%) were men. Mean age was 37 years (interquartile range: 31-43). Consistent condom use for men and women was below 60% for all partner types. In multivariate analysis, unprotected sex was more likely among women (odds ratio [OR]: 1.9, 95% confidence interval [CI]: 1.2-3.1, P = 0.007), those with HIV diagnoses within the past year (OR: 2.0, 95% CI: 1.1-3.7, P = 0.016), those reporting difficulty accessing condoms (OR: 2.6, 95% CI: 1.4-4.7, P = 0.003), and those reporting discrimination (OR: 1.8, 95% CI: 1.1-3.0, P = 0.016).

CONCLUSIONS

Programs targeting HIV-positive patients need to address gender-based disparities, improve condom access and use, and help establish a protective legal and policy environment free of stigma and discrimination.

Is HIV/AIDS a consequence or divine judgment? Implications for faith-based social services. A Nigerian faith-based university's study

A contemporary reading of Romans 1:27 was disguised as a saying by Paul Benjamin, AD 58 and administered to 275 randomly selected members of a private Christian university community in south western Nigeria in West Africa. Participants were asked to respond to a two-item questionnaire on their perception of the cause of HIV/AIDS either as a judgment from God or consequence of individual lifestyle choices. The apparent consensus drifted in the direction of God as the culprit handing down his judgment to perpetrators of evil who engage in the homosexual lifestyle. The goal of this paper was to examine the implications of a judgmental stance on addressing the psychosocial needs of Persons Living with HIV/AIDS in religious environments. It also explores how service providers in faith-based environments can work around the Judgment versus Consequence tussle in providing non-discriminatory services to persons diagnosed with HIV/AIDS.

HIV-Related discrimination in European health care settings

This cross-sectional European study assessed self-reported HIV-related discrimination and its associated factors in health care settings. Socio-demographics, health status, support needs relating to sexual and reproductive health (SRH), and self-reported HIV-related discrimination were measured using an anonymous survey in a sample of 1549 people living with HIV from 14 countries. Thirty-two per cent of the participants had experienced HIV-related discrimination during the previous 3 years; almost half of them felt discriminated against by health care providers. For this type of discrimination, logistic regression analysis revealed significant associations with not being a migrant (OR: 2.0; IC 1.0-3.7; p<0.05), having been forced into sexual activities (OR: 1.6; IC 1.2-2.2; p<0.001), reporting lack of time to discuss SRH during service provision (OR: 1.7; IC 1.0-2.7; p<0.05), and insufficient openness among service providers to discuss SRH (OR: 2.0; IC 1.1-3.4; p<0.05). Other significant associations related to unmet support needs on safer sex practices (OR: 1.8; IC 1.0-3.2; p<0.05), partner communication about sexuality (OR: 2.0; IC 1.1-3.4; p<0.05), and prevention of sexually transmitted infections (OR: 1.7; IC 1.0-3.0; p<0.05). Female gender had a protective effect (OR: 0.2; IC 0.0-0.9; p<0.05). Being denied the opportunity to discuss SRH may translate in feelings of discrimination. Improving health care providers' communication skills, and fostering openness about SRH topics in HIV care could contribute to destigmatization of PLHIV.

The impact of anticipated HIV stigma on delays in HIV testing behaviors: findings from a community-based sample of men who have sex with men and transgender women in New York City

Treatment as prevention (TaSP) is a critical component of biomedical interventions to prevent HIV transmission. However, its success is predicated on testing and identifying undiagnosed individuals to ensure linkage and retention in HIV care. Research has examined the impact of HIV-associated stigma on HIV-positive individuals, but little work has explored how anticipated HIV stigma-the expectation of rejection or discrimination against by others in the event of seroconversion-may serve as a barrier to HIV testing behaviors. This study examined the association between anticipated stigma and HIV testing behaviors among a sample of 305 men who have sex with men (MSM) and transgender women living in New York City. Participants' mean age was 33.0; 65.5% were racial/ethnic minority; and 50.2% earned <$20,000 per year. Overall, 32% of participants had not had an HIV test in the past 6 months. Anticipated stigma was negatively associated with risk perception. In multivariate models, anticipated stigma, risk perception, and younger age were significant predictors of HIV testing behaviors. Anti-HIV stigma campaigns targeting HIV-negative individuals may have the potential to significantly impact social norms around HIV testing and other biomedical strategies, such pre-exposure prophylaxis, at a critical moment for the redefinition of HIV prevention.

Beliefs and attitudes of medical students from public and private universities in Malaysia towards individuals with HIV/AIDS

We describe the findings from a survey assessing the beliefs regarding testing, confidentiality, disclosure, and environment of care and attitudes towards care of people with HIV/AIDS (PLHWA), in 1020, 4th and 5th year medical students, from public and private medical universities in Malaysia. A self-administered validated questionnaire based on the UNAIDS Model Questionnaire with a 5-point Likert scale (5, strongly disagree; 4, disagree; 3, neutral; 2, agree; 1, strongly agree) was used as a survey tool. The survey included demographic data and data on undergraduate training received on HIV/AIDS. Statistical significance in the demographic data and training received by respondents was evaluated using the chi-square test while the independent Student's t-test was used for comparison of means between public and private universities. A P value of <0.05 was considered statistically significant with 95% confidence interval. Our study revealed less than 20% of medical students received adequate training to care for PLHWA. They had prevalent negative beliefs regarding testing, confidentiality, disclosure and environment of care towards PLHWA although in giving care to PLHWA, their attitudes were largely positive and nondiscriminatory.

Inconsistent condom use among HIV-positive women in the "Treatment as Prevention Era": data from the Italian DIDI study

Introduction

Translation of the evidence regarding the protective role of highly active antiretroviral therapy (HAART) on HIV sexual transmission rates into sexual behaviour patterns of HIV-infected subjects remains largely unexplored. This study aims to describe frequency of self-reported condom use among women living with HIV in Italy and to investigate the variables associated with inconsistent condom use (ICU).

Methods

DIDI (Donne con Infezione Da HIV) is an Italian multicentre study based on a questionnaire survey performed during November 2010 and February 2011. Women-reported frequency of condom use was dichotomized in “always” versus “at times”/“never” (ICU).

Results

Among 343 women, prevalence of ICU was 44.3%. Women declared a stable partnership with an HIV-negative (38%) and with an HIV-positive person (43%), or an occasional sexual partner (19%). Among the 194 women engaged in a stable HIV-negative or an occasional partnership, 51% reported fear of infecting the partner. Nonetheless, 43% did not disclose HIV-positive status. Less than 5% of women used contraceptive methods other than condoms. At multivariable analysis, variables associated with ICU in the subgroup of women with a stable HIV-negative or an occasional HIV-unknown partner were: having an occasional partner (AOR 3.51, 95% confidence interval [CI] 1.44–8.54, p=0.005), and reporting fear of infecting the sexual partner (AOR 3.20, 95% CI 1.43–7.16, p=0.004). Current use of HAART together with virological control in plasma level did not predict ICU after adjusting for demographic, behavioural and HIV-related factors. With regard to socio-demographic factors, lower education was the only variable significantly associated with ICU in the multivariate analysis (AOR 2.27, 95% CI 1.07–4.82, p=0.03). No association was found between high adherence to HAART and ICU after adjusting for potential confounders (AOR 0.89, 95% CI 0.39–2.01, p=0.78).

Conclusions

Currently in Italy, the use of HAART with undetectable HIV RNA in plasma as well as antiretroviral adherence is not associated with a specific condom use pattern in women living with HIV and engaged with a sero-discordant or an HIV-unknown partner. This might suggest that the awareness of the protective role of antiretroviral treatment on HIV sexual transmission is still limited among HIV-infected persons, at least in this country.

Disclosure behaviour and experienced reactions in patients with HIV versus chronic viral hepatitis or diabetes mellitus in Germany

Disclosure is a prerequisite to receive disease-specific social support. However, in the case of a stigmatised disease, it can also lead to discrimination. We aimed to assess disclosure rates of HIV patients and the reactions they encountered in comparison to patients with chronic viral hepatitis or diabetes mellitus and patients' general perception of disease-specific discrimination. We constructed a self-report questionnaire, anonymously assessing the size of the social environment, the persons who had been informed, and the experienced reactions as perceived by the disclosing patients, to be rated on 1-4 point Likert scales. In addition, patients were asked whether they perceive general discrimination in Germany. One hundred and seventy-one patients were asked to participate. Five rejected, thus questionnaires from 83 patients with HIV, 42 patients with chronic viral hepatitis B (n = 9) or C (n = 33), and 41 patients with insulin-dependent diabetes mellitus (type I n = 14, type II n = 27) were analysed. Whereas the size of the social environment did not differ, HIV-infected patients were least likely to disclose their disease (60.7%, SD ± 31.9) to their social environment as compared to patients with chronic viral hepatitis (84.2 ± 23.3%, p<0.0001), or diabetes mellitus (94.4 ± 10.3%, p<0.0001), respectively. Within the HIV patient group, the mean disclosure rate was highest to partners (90.9%), followed by the public environment (65.2%), friends (59.4%) and family members (43.8%). HIV patients experienced supportive reactions after 79.3 ± 26.4% of disclosures, which was the case in 91.4 ± 19.6% and 75.7 ± 36.1% of patients with hepatitis or diabetes mellitus, respectively. 69.5% of HIV patients stated to perceive general discrimination in Germany. We conclude that HIV patients had experienced supportive reactions after the majority of disclosures, but the low rate points out that their information strategy had been very selective. Societal discrimination of HIV patients is still an issue and needs to be further addressed.

The impact of living with HIV: differences in experiences of stigma for heterosexual and homosexual people living with HIV in Australia

Background HIV in Australia has been closely aligned with the gay community and continues to disproportionately affect members of this community. Although heterosexual transmission remains low, recently there has been an increase in new HIV diagnoses attributable to heterosexual sex. This highlights the need to address the health and social consequences for heterosexual people living with HIV (PLHIV). This subanalysis of a larger study compared the experiences of stigma, health and wellbeing of a sample of gay and heterosexual PLHIV. Methods: Data were drawn from a study of experiences of stigma among PLHIV in Australia. All 49 participants who reported being heterosexual were included, as were 49 participants randomly selected from the 611 gay participants. The samples were compared on perceived HIV stigma, HIV treatment-related stigma, perceived negative reactions of others, HIV status disclosure, and health and wellbeing measures. Results: The findings illustrate that heterosexual PLHIV have more negative experiences in terms of both general HIV stigma and treatment-related stigma than gay PLHIV. The heterosexual PLHIV also perceived greater negative reactions in relation to their HIV status by different people in their social environment and were less likely to access treatment than the gay PLHIV. There were no differences between the two groups in any of the health and wellbeing measures. Conclusions: This study shows that in the Australian context, heterosexual PLHIV may feel more stigmatised than gay PLHIV. In view of lower HIV treatment uptake in heterosexual PLHIV, addressing HIV-related stigma could contribute to increasing access to HIV treatment.

Mapping HIV community viral load: space, power and the government of bodies

HIV plasma viral load testing has become more than just a clinical tool to monitor treatment response at the individual level. Increasingly, individual HIV plasma viral load testing is being reported to public health agencies and is used to inform epidemiological surveillance and monitor the presence of the virus collectively using techniques to measure 'community viral load'. This article seeks to formulate a critique and propose a novel way of theorizing community viral load. Based on the salient work of Michel Foucault, especially the governmentality literature, this article critically examines the use of community viral load as a new strategy of government. Drawing also on the work of Miller and Rose, this article explores the deployment of 'community' through the re-configuration of space, the problematization of viral concentrations in specific microlocales, and the government (in the Foucauldian sense) of specific bodies which are seen as 'risky', dangerous and therefore, in need of attention. It also examines community viral load as a necessary precondition - forming the 'conditions of possibility' - for the recent shift to high impact prevention tactics that are being scaled up across North America.

Sexual behavior as a function of stigma and coping with stigma among people with HIV/AIDS in rural New England

The relationship between coping with HIV/AIDS stigma and engaging in risky sexual behavior (i.e., inconsistent condom use) was examined in HIV-positive adults living in rural areas. Participants answered questions about their experiences with HIV/AIDS prejudice and discrimination (enacted stigma) and their perceptions of felt HIV/AIDS stigma (disclosure concerns, negative self-image, and concern with public attitudes). They were also asked about how they coped with HIV/AIDS stigma, and about their sexual activity during the past 90 days. We hypothesized that using disengagement coping to manage the stress of HIV/AIDS stigma would be related to risky sexual behavior. Multinomial logistic regression results showed that using disengagement coping (avoidance, denial, and wishful thinking) coupled with high levels of enacted stigma was associated with less risky rather than more risky sexual behavior. That is, disengagement coping coupled with high stigma increased the odds of not having vaginal or anal sex versus inconsistently using condoms. Implications for people with HIV/AIDS who use disengagement coping to manage stress to deal with HIV/AIDS stigma are discussed.

Trends in unsafe sex and influence of viral load among patients followed since primary HIV infection, 2000-2009

BACKGROUND

In the current context of increasing unsafe sex, HIV incidence may have evolved, depending on HIV prevalence in sexual networks and, among HIV-infected persons who practice unsafe sex, on their infectivity and partners' HIV serostatus. We examined calendar trends in sexual behaviours at risk of HIV-1 transmission (SBR) among 967 adults followed since primary HIV infection (ANRS PRIMO cohort) and relationship with current treatments and viral load.

METHODS

Patients completed since 2000 self-administered questionnaires on sexual practices every 6 months. SBR with HIV-negative/unknown partners were analyzed among 155 heterosexual women, 142 heterosexual men and 670 MSM by using logistic generalized estimating equation models (6656 visits).

RESULTS

During 2000-2009, the frequency of SBR did not increase significantly among women with steady partners; risk factors were a low education level and alcohol/smoking use. Among heterosexual men with steady partners, the frequency of SBR doubled since 2006; during this period, the only associated factor was combined antiretroviral treatment for at least 6 months or viral load less than 400 copies/ml. Among MSM, SBR increased gradually over time; SBR with steady partners was associated with a low education level and alcohol use. SBR was more frequent among MSM with casual partners; no association with viral load was found.

CONCLUSION

In France, recent trends and risk factors in unprotected sex with HIV-negative/unknown partners differ according to sex/sexual preference. The recent increase in SBR among heterosexual men with low viral load may be related to increasing awareness of the 'treatment-as-prevention' concept. The lack of association between SBR and viral load among MSM supports use of treatment-as-prevention as part of diversified prevention strategies.

Harmful alcohol consumption and patterns of substance use in HIV-infected patients receiving antiretrovirals (ANRS-EN12-VESPA Study): relevance for clinical management and intervention

Alcohol abuse affects secondary prevention and disease progression in HIV-infected patients, and adherence and response to treatment in those chronically treated. The objective of this study was to estimate the prevalence of harmful alcohol consumption (HAC) using various indicators and identify which groups of patients may require specific targeted interventions for HAC risk reduction. A cross-sectional survey, based on a random sample representative of people living with HIV/AIDS (PLWHA) was carried out in 102 French hospital departments delivering HIV care. As alcohol abuse is particularly detrimental to patients receiving highly active antiretroviral therapy (HAART), we focused only on those individuals receiving HAART with complete alcohol assessment (CAGE, AUDIT-C, regular binge drinking, N=2340). Collected information included medical and socio-demographic data, HIV risk behaviors, adherence to treatment and substance and alcohol use, together with depression, anxiety, and experience of attempted suicide or sex work. HAC prevalence was evaluated as follows: 12% (CAGE score > or =2), 27% (AUDIT-C), and 9% (regular binge drinking). Three groups were at higher risk of HAC: men who have sex with men using stimulants, polydrug users, and to a lesser degree, ex-drug users. Innovative intervention strategies to reduce HAC and improve HIV prevention and HAART adherence in various PLWHA populations need urgent testing and implementation. Such interventions for alcohol risk reduction remain central to promoting improved HIV prevention and assuring HAART effectiveness in these populations.

Quality of life assessment in HIV clinical research in resource-limited settings: better late than never

Comprehensive and sustained optimal care for patients infected with HIV can now be achieved in resource-constrained settings, thanks to the sustainability of programs providing antiretroviral therapy (ART). But the primary goals of HIV virological suppression and improved survival need to be accompanied by a substantial improvement in patient's experience with HIV care and treatment. An assessment of both patients' quality of life and perceived toxicity and symptoms should now be systematically integrated into HIV clinical research in resource-constrained countries. This will allow treatment strategies aimed at optimizing the durability of response to ART in these settings to be properly evaluated and compared.

HIV prevention intervention to reduce HIV-related stigma: evidence from China

BACKGROUND

The National Institute of Mental Health Collaborative HIV/Sexually Transmitted Disease Prevention Trial provided a unique opportunity to test whether, with the community-based diffusion of HIV/sexually transmitted disease prevention information and an elevated understanding of HIV, the level of stigmatizing attitudes toward people living with HIV/AIDS in the community would be reduced.

METHOD

A total of 4510 market workers in Fuzhou, China, participated in the study, and longitudinal analyses included study samples of 3785 participants in the 12-month follow-up and 3716 participants in the 24-month follow-up. We graphically examined the change in HIV-related stigma indicators over time between control and intervention groups using boxplot and kernel density estimation. A logistic regression analysis with proportional odds model was further used to examine the intervention effect on HIV-related stigmatizing attitudes.

RESULTS

Compared with no change over time for the control group, the intervention successfully reduced the level of HIV-related stigmatizing attitudes among the target population at the 12-month follow-up, and the effect increased by two-fold (with respect to odds ratios) at the 24-month follow-up.

DISCUSSION

The intervention demonstrated positive attitude changes associated with HIV-related stigma. Our results show the importance of social norms, rather than simply individual behaviors, in developing and implementing stigma reduction campaigns.

Individual- and community-level determinants of social acceptance of people living with HIV in Kenya: results from a national population-based survey

Using the 2003 Kenya Demographic and Health Survey, we investigated the influence of individual- and community-level factors on accepting attitudes toward people living with HIV (PLHIV) using three outcomes: (1) willingness to care for an infected household member, (2) willingness to buy vegetables from an infected vendor, and (3) willingness to allow an infected female teacher to continue teaching. In multilevel logistic regression models, we found that individuals who expressed greater acceptance of PLHIV were more likely to be male, older, more educated, high AIDS knowledge, and exposed to mass media. At the community level, differences in accepting attitudes were associated with community AIDS knowledge, community education, and community AIDS experience, but not for region, or place of residence. The findings suggest the important role of community factors in determining social acceptance of PLHIV. Programmatic strategies aimed at increasing these accepting attitudes should consider both individual- and community-level factors.

HIV prevention: What have we learned from community experiences in concentrated epidemics?

Drawing on lessons learned from community experiences in concentrated epidemics, this paper explores three imperatives in the effort to reduce the sexual transmission of HIV: combat prevention fatigue, diversify HIV testing and combat stigma and discrimination. The paper argues for a non-judgmental harm reduction approach to the prevention of sexual transmission of HIV that takes into account the interpretation of risk by diverse individuals and communities in the era of antiretroviral therapy. This approach requires greater attention to increasing access to opportunities to know one's serostatus, especially among key populations at greater risk. Novel approaches to diversifying HIV testing approaches at community level are needed. Finally, the paper makes a plea for bold measures to combat stigma and discrimination, which continues to represent a formidable barrier for access to services for affected populations and may contribute to HIV-related risk behaviours. A "triple therapy" approach to address stigma and discrimination is discussed, which includes greater acceptance of people living with HIV and AIDS (PLWHA), improving relevant laws and policies, and involving prevention users- working with people rather than for people-.Note: this paper corresponds to the plenary talk of Bruno Spire at the XVIIth World AIDS Conference, August 8th, Mexico city: http://www.kaisernetwork.org/health_cast/player.cfm?id=4383.

Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward

Although stigma is considered a major barrier to effective responses to the HIV/AIDS epidemic, stigma reduction efforts are relegated to the bottom of AIDS programme priorities. The complexity of HIV/AIDS-related stigma is often cited as a primary reason for the limited response to this pervasive phenomenon. In this paper, we systematically review the scientific literature on HIV/AIDS-related stigma to document the current state of research, identify gaps in the available evidence and highlight promising strategies to address stigma. We focus on the following key challenges: defining, measuring and reducing HIV/AIDS-related stigma as well as assessing the impact of stigma on the effectiveness of HIV prevention and treatment programmes. Based on the literature, we conclude by offering a set of recommendations that may represent important next steps in a multifaceted response to stigma in the HIV/AIDS epidemic.

HIV-related discrimination reported by people living with HIV in London, UK

The objective was to examine the extent to which people living with HIV in London reported being discriminated against because of their infection. In 2004-2005, people living with HIV attending NHS outpatient HIV clinics in north east London were asked: "Have you ever been treated unfairly or differently because of your HIV status-in other words discriminated against?". Of the 1,687 people who returned a questionnaire (73% response rate), data from 1,385 respondents were included in this analysis; 448 heterosexual women and 210 heterosexual men of black African origin, 727 gay/bisexual men (621 white, 106 ethnic minority). Overall, nearly one-third of respondents (29.9%, 414/1,385) said they had been discriminated against because of their HIV infection. Of those who reported experiencing HIV-related discrimination, almost a half (49.6%, 200/403) said this had involved a health care worker including their dentist (n = 102, 25.3%) or primary care physician (n = 70, 17.4%).

Individual, social, and environmental influences associated with HIV infection among injection drug users in Tijuana, Mexico

OBJECTIVE

We examined correlates of HIV infection among injection drug users (IDUs) in Tijuana, Mexico, a city bordering the United States, which is situated on major migration and drug trafficking routes.

METHODS

IDUs aged > or =18 years were recruited using respondent-driven sampling. Participants underwent antibody testing for HIV and syphilis and structured interviews. Weighted logistic regression identified correlates of HIV infection.

RESULTS

Of 1056 IDUs, the median age was 37 years, 86% were male, and 76% were migrants. HIV prevalence was higher in female participants than in male participants (8% vs. 3%; P = 0.01). Most IDUs testing HIV-positive were previously unaware of their serostatus (93%). IDUs reported injecting with a median of 2 people in the prior 6 months and had been arrested for having injection stigmata (ie, "track-marks") a median of 3 times. Factors independently associated with HIV infection were being female, syphilis titers consistent with active infection, larger numbers of recent injection partners, living in Tijuana for a shorter duration, and being arrested for having track-marks.

CONCLUSIONS

Individual, social, and environmental factors were independently associated with HIV infection among IDUs in Tijuana. These findings suggest the need to intervene not solely on individual risk behaviors but on social processes that drive these behaviors, including problematic policing practices.