Community Cultural Norms, Stigma and Disclosure to Sexual Partners among Women Living with HIV in Thailand, Brazil and Zambia (HPTN 063)

HIV status disclosure in the era of treat-all: the complexities of societal expectations and disclosure in marital relationships in Shinyanga, Tanzania

Robust advancements in clinical treatment of people living with HIV (PLHIV) have resulted in the current "treatment as prevention" strategy: the inability to transmit the virus when it is undetectable. Nevertheless, disclosure within marital relationships remains important to adhere optimally to treatment and further limit transmission in the era of treat-all. Disclosure, however, can have serious social repercussions, particularly for women. This paper examines gendered disclosure decisions and their social consequences in marital relationships in Tanzania. Drawing from a 9-month ethnographic study in Shinyanga Region, we explore how Sukuma societal values shape disclosure decisions. In-depth interviews with 103 PLHIV and 19 FGDs inform our analysis. We found that societal values regarding gender and marriage significantly influence disclosure decisions in marital relationships. The HIV treat-all approach, with its focus on early treatment initiation preserved health and inability to transmit allowed men and women to carefully weigh the costs and benefits of disclosure to their marital aspirations. The benefits of antiretroviral treatment for social relations are often overlooked in medical interventions. We conclude that to reduce difficult disclosure decisions for PLHIV, emphasising community awareness of HIV treatment as prevention to mitigate the negative impacts of disclosure is needed.

Perceived levels of social stigma following HIV notification: Insights from Brazilian blood centers

BACKGROUND

HIV/AIDS remains a highly stigmatizing disease worldwide, preventing people with risk or infection from testing to learn their HIV status, accessing supportive services, or taking antiretroviral therapy. Despite many studies of HIV in blood donors, no studies have evaluated the factors that contribute to stigma surrounding this illness following notification process and counseling provided by blood centers.

METHODS

A cross-sectional questionnaire-based survey was conducted between 2016 and 2017. Persons with HIV were invited to return to the blood center for an audio computer-assisted interview after participation in an HIV risk factor assessment study conducted from 2007 to 2016. The questionnaire was based on HIV risk interviews developed by the US CDC, with modifications appropriate to the Brazilian setting which aimed to evaluate their follow-up activities, perceptions of HIV stigma and discrimination, and the quality of counseling and notification after the donation that tested positive for HIV. Response frequencies and adjusted odds ratios from multivariable logistic regression analyses are reported.

RESULTS

268 HIV-positive blood donors agreed to participate in the study. Almost all participants, 262 (97 %), rated as very important or important the blood center counseling experience in their decision to seek health care. One-hundred-five (39 %) participants reported none to low levels of stigma, and 163 (61 %) participants moderate stigma. Individuals reporting heterosexual orientation (OR=2.13, 95 % CI [1.08‒4.22]) and healthcare-seeking behavior (OR=2.46, 95 % CI [1.10‒5.48]) had significantly increased odds of reporting moderate levels of stigma.

CONCLUSIONS

Our study provides information about perceived stigma and discrimination in the Brazilian blood donor population and reinforces the importance of the counseling process in linkage to care and reducing HIV-related stigma.

Influence of Knowledge of Stigmatization and Discriminatory Practices against HIV-Positive Persons on Pregnant Women's HIV Testing in Nigeria

Background

Stigmatizing and discriminatory attitudes have been reported as factors militating against the control of the spread of HIV infection and ending the HIV epidemic. Women of reproductive age identified as a vulnerable group to HIV infection require comprehensive knowledge of HIV transmission and prevention to prevent contracting HIV infection. Therefore, this study aimed to determine the association between reproductive-age women's comprehensive knowledge of HIV transmission and prevention and their stigmatizing and discriminatory attitudes toward individuals living with HIV/AIDS.

Methodology

Secondary data from the 2018 Nigerian Demographic and Health Survey was used for this study. We used in each analysis a weighted sample of women of reproductive age with complete data on the comprehensive knowledge of HIV transmission and prevention and stigmatizing and discriminatory attitudes towards persons living with HIV/AIDS. Bivariable and multivariable logistic regression analysis was done to predict the effects of the comprehensive knowledge of HIV transmission and prevention of women of reproductive age on their stigmatizing and discriminatory attitudes toward persons living with HIV/AIDS. Predictor variables with a p-value of ≤ 0.05 were considered statistically significant determinants of HIV/AIDS stigmatizing and discriminatory attitudes.

Results

The number of respondents with HIV/AIDS stigmatizing and discriminatory attitudes was 22821 (77.0%). The multivariable regression models showed that women with an average household wealth index, of Islamic faith, and no access to media were more likely to have positive attitudes toward persons living with HIV at Alpha = .05.

Conclusion

Having comprehensive knowledge of HIV transmission and prevention by women of reproductive age did not affect their HIV stigmatizing and discriminatory attitudes towards individuals living with HIV/AIDS differently when compared to those without comprehensive knowledge. The findings that women with no access to media and those with an average household wealth index were more likely to have a positive attitude towards persons living with HIV/AIDS than those with access to media and a rich household wealth index, respectively, require further validation using primary data.

Predictors of HIV Testing Among Pregnant Women aged 15-49 Years in Nigeria

Background

The utilization of HIV testing services in Nigeria has not been optimal due to socioeconomic and demographic factors such as educational level, place of residence, and religion. For Nigeria to achieve epidemic control, pregnant women need to know their HIV status through HIV testing, which is the gateway to HIV prevention, care, support, and treatment services. Therefore, the purpose of this study was to determine the predictors of HIV testing among Nigerian pregnant women aged 15-49 years HIV testing during antenatal visits or childbirth.

Methodology

Secondary data analyses of 659 pregnant women randomly selected from the multiple imputation datasets of the 2013 Nigeria Demographic and Health Survey (NDHS)were done using SPSS version 25. Data on socio-demographic characteristics, HIV stigmatizing attitudes, and HIV testing were retrieved from the dataset for the study. Bivariate and multivariate regression analyses were done to determine the predictors of HIV testing.

Results

The prevalence of self-reported HIV testing and receiving results among women of reproductive age was 36.72%. Bivariate model findings showed that educational level, place of residence, and religion were statistically significant predictors of HIV testing among pregnant women. Only educational level and place of residence significantly predicted pregnant women's HIV testing in the parsimonious multivariable regression model. Pregnant women with higher levels of education (Primary Education, AOR, 1.85; 95% CI, 1.07,3.19; Secondary Education, AOR, 3.75; 95% CI:1.93, 7.28; Higher Education, AOR, 11.23; 95% CI: 4.40, 28.68) and those living in urban areas (AOR, 1.60: 95% CI:1.03, 2.47) were more likely to test for HIV than those with no education and those living in the rural areas.

Conclusion

This study identified having a higher level of education and living in urban areas as predictors of HIV testing, therefore, more efforts are needed to have women with lower levels of education and those living in rural areas test for HIV as a strategy for the elimination of mother-to-child transmission of HIV.

Influence of knowledge about discriminatory practices towards HIV positive individuals with the uptake of HIV testing during pregnancy among reproductive-aged women in Nigeria

Background

The fear of positive HIV results has been reported as a determinant of HIV testing among pregnant women and women of reproductive age. When pregnant women know about discriminatory practices toward other people based on their HIV-positive status, it may impact their testing for HIV. Therefore, the purpose of this study was to examine the association between Nigerian pregnant women's knowledge of discriminatory practices against persons living with HIV and their self-reported HIV testing during antenatal visits or childbirth.

Methodology

A secondary analysis of data from 659 t women who had experienced pregnancy aged 15-49 years from the 2013 Nigeria Demographic Health Survey (NDHS) was done. Multivariable logistic regression analysis was done to determine the association between knowledge about discriminatory practices towards HIV-positive individuals (independent variable) and HIV testing during pregnancy (dependent variable) after controlling for covariates (demographic characteristics). A P-value of ≤ 0.05 was taken as statistically significant.

Results

Bivariate logistic regression analysis findings showed that educational level, place of residence, and religion statistically significantly predicted HIV testing of pregnant women, while age categories and marital status did not. The women's knowledge of discriminatory practices towards persons living with HIV/AIDS was not statistically significant at Alpha = 0.05 (AOR,1.51; 95% CI: .46, 4.95) Higher levels of education (Primary Education, AOR = 1.81; 95% CI: 1.03, 3.18; Secondary Education, AOR = 3.73; 95% CI: 1.92, 7.25; Higher Education, AOR = 10.92; 95% CI: 4.25, 28.05) and those living in urban areas (AOR = 1.62; 95% CI: 1.04, 2.51) were significantly associated with testing for HIV in the stepwise multivariable regression model of pregnant women's knowledge of discriminatory practices towards persons living with HIV/AIDS.

Conclusion

Although knowledge of discriminatory practices did not predict pregnant women's HIV testing in this study, interventions by stakeholders to eliminate or reduce these practices should be stepped up towards facilitating positive social change.

A Systematic Review of the Impact of HIV-Related Stigma and Serostatus Disclosure on Retention in Care and Antiretroviral Therapy Adherence Among Women with HIV in the United States/Canada

This systematic review explores the roles of HIV stigma and disclosure of HIV serostatus in antiretroviral therapy (ART) adherence and retention in care (RIC) among women with HIV (WHIV) in the United States and Canada. We conducted a systematic search of electronic databases (PubMed, Embase, CINAHL, PsycINFO, and Google scholar) to identify peer-reviewed articles published between January 1996 and December 2022. The search yielded 1120 articles after duplicates were removed. Of these, 27 articles met the inclusion criteria. The majority (89%) of the studies were conducted in the United States. The studies included WHIV from diverse racial/ethnic groups, residing in both urban and rural areas. Most of the studies suggested that internalized stigma, perceived community stigma, and fear of disclosure were important barriers to ART adherence and RIC among WHIV. HIV-related stigma experienced within the health care setting was also reported as a factor impacting health care utilization. A few studies identified mental health distress as a potential mechanism accounting for the association and suggested that social support and resilience may buffer the negative effects of stigma and disclosure on ART adherence and RIC among WHIV. Our review indicates that stigma and concerns about disclosure continue to significantly affect HIV health outcomes for WHIV in high-income countries. It underscores the importance of integrated HIV care services and interventions targeting mental health, resilience building, and improved patient-provider relationships for WHIV to enhance ART adherence and RIC. Longitudinal studies and investigations into additional mechanisms are needed to advance understanding and inform women-centered interventions.

How does HIV-related stigma correlate with HIV prevalence in African countries? Distinct perspectives from individuals living with and living without HIV

BACKGROUND

Population-level research evaluating HIV-related stigma among countries with varied national HIV prevalence is scarce. To better understand HIV-related stigma and mitigate its potential negative effects, it is necessary to evaluate its relationship with HIV prevalence, as well as the mechanisms that influence it. This study aimed to analyze how HIV-related stigma correlates with subnational HIV prevalence in three African countries with varied HIV epidemics.

METHODS

This paper used data from the nationally representative Population-based HIV Impact Assessment (PHIA) surveys conducted from 2015-2017 in Malawi, Zambia, and Tanzania. Each country's sub-national geographic divisions were used to categorize them as low (0-5.4%), middle (5.5-11.2%), and high (11.3-17.1%) HIV prevalence regions in the main analysis. Questions from the survey stigma module were used to measure HIV-related stigma. Logistic regression and multilevel models were performed to assess the associations between the level of sub-national HIV prevalence and HIV-related stigma measures among persons living with, and without, HIV.

RESULTS

The results show that the odds of people living without HIV expressing stigmatizing behavior towards PLWH was significantly lower in regions of middle (OR = 0.80, 90%CI = (0.68-0.96)) and high (OR = 0.65, 90%CI = (0.53-0.80)) HIV prevalence when compared to low prevalence regions. The odds of reporting discriminatory attitudes were also lower for those in middle (OR = 0.87, 90%CI = (0.78-0.98)) and high (OR = 0.64, 90%CI = (0.56-0.73)) HIV prevalence regions compared to others. Living in middle and high HIV prevalence regions was associated with lower odds of expressing prejudice toward PLWH (OR = 0.84, 90%CI = (0.71-0.99) and OR = 0.60, 90%CI = (0.45-0.80), respectively) among people living without HIV. Notably, PLWH living in high prevalence regions had higher odds of reporting internalized stigma (OR = 1.48, 90%CI = (1.02-2.14)) compared to those living in low prevalence regions.

CONCLUSIONS

The results indicate that among people not living with HIV, subnational HIV prevalence was negatively associated with discriminatory attitudes and prejudice towards PLWH, but HIV prevalence was positively associated with self-reported internalized stigma among PLWH. These results provide insight on how resources could be invested to reduce HIV related stigma among both PLWH and those not living with HIV.

Characterization of HIV-Related Stigma in Myanmar

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

Health disclosure mediates stigma-psychological well-being link among Vesico-Vaginal fistula patients

There is strong link between health stigma and poor psychological wellbeing among Vesico-Vaginal fistula (V.V.F.) patients, yet no study to date has investigated the variables mediating this link. This study investigated the mediating role of health disclosure on the relationship between health stigma and psychological wellbeing among V.V.F. patients in Nigeria. Participants were 183 women (aged 14-70 years; mean age 22.88 years, SD = 5.64) conveniently drawn from a National Obstetric Fistula Hospital facility in south-east Nigeria. Participants completed measures of health stigma, health disclosure and psychological wellbeing. Results showed that health disclosure mediated the association between health stigma and psychological wellbeing. The results indicated that increased health stigma would lead to decreased health disclosure which in turn, would lead to poor psychological wellbeing. Our findings highlighted the relevance of health disclosure in the management of stigma impacts on health and wellbeing of V.V.F. patients.

Mixed studies review of domestic violence in the lives of women affected by HIV stigma

We conducted a mixed studies review to examine domestic violence and stigma against women affected by HIV. We searched Medline, Web of Science, PsycINFO and EMBASE databases with no starting date limit. Studies that reported on experiences of stigma, discrimination, or domestic violence against women affected by HIV in any country were included. Because the review focused on HIV stigma-related violence, we only included studies that reported violence following an HIV diagnosis or at the time of HIV testing. A total 1056 records were screened; 89 articles were assessed for full text eligibility and 49 studies were selected for evidence synthesis. A convergent approach was used and study findings were analysed thematically. Four broad themes emerged: (1) being affected by HIV increases domestic violence, (2) supportive reactions from partners, (3) HIV stigma is associated with domestic violence, and (4) domestic violence associated with HIV-stigma is gendered. Research gaps identified included the burden of intersectional stigma of domestic violence and HIV, and the mediating role of HIV stigma in domestic violence for women with HIV, highlighting the need for further research in this area to reduce violence against women living with HIV.

Predictors of Multiple Sexual Partners among Men in Ethiopia: A Multilevel Analysis

Background

Multiple sexual partnerships were one of the public health issues in the spread of high rates of sexually transmitted infections in sub-Saharan regions. An increase in the number of non-marital sexual partners can lead to a loss of satisfaction as well as other mental health repercussions such as greater rates of anxiety, depression, etc. This study examined the predictors of multiple sexual partners among men in Ethiopia.

Methods

This study used 2016 nationally representative data which was conducted using a multistage stratified cluster sampling method. Multilevel binary logistic regression models were employed to estimate the predictors of multiple sexual partners among men in Ethiopia with the assistance of the STATA software.

Results

In this study 6778 participants were considered with an overall prevalence rate of multiple sexual partners of 6.5% during the 12 months preceding the survey. The findings showed that older-age, urban-resident, inconsistent use of a condom, exposure to any media, abuse of alcohol, early-time first-sex, and religion were predictors of multiple sexual partners among men in Ethiopia.

Conclusions

The findings revealed that the prevalence rate of men's multiple sexual partners in Ethiopia was very high. Therefore, the country needs to re-examine the behavioral change strategies periodically to adapt to the contextual realities and engage relevant stakeholders. Specifically, health sectors and religious organizations should develop strategies to create awareness in society on the risk of having multiple sexual partnerships. In addition, we highly recommend stakeholders prepare risk reduction interventions that take the significant predictors of multiple sexual partners.

Stigma Determines Antiretroviral Adherence in Adults With HIV in Myanmar

INTRODUCTION

Understanding social and structural barriers that determine antiretroviral therapy (ART) adherence can improve care. Assessment of such factors is limited in Myanmar, a country with high HIV prevalence and increasing number of people living with HIV initiating ART.

METHODS

Questionnaires were administered to adults with HIV across 4 Myanmar cities to estimate adherence and its potential determinants, including HIV knowledge, social support, barriers to care, enacted and internalized stigma, and engagement in peer-to-peer HIV counseling (PC). Associations were determined using logistic mixed-effects modeling.

RESULTS

Among 956 participants, the mean age was 39 years, 52% were female, 36% had CD4 <350 cells/mm3, and 50% received pre-ART PC. Good adherence was reported by 74% of participants who had better HIV knowledge than those reporting nonadherence. Among nonadherent, 44% were forgetful and 81% were careless about taking ART. Among all participants, most (53%) were very satisfied with their social support and 79% reported lack of financial resources as barriers to care. Participants most frequently reported being viewed differently by others (30%) and feeling as if they were paying for past karma or sins because of their HIV diagnosis (66%). Enacted stigma (odds ratio 0.86; 95% confidence interval 0.79 to 0.92, P < 0.01) and internalized stigma (odds ratio 0.73; 95% confidence interval: 0.56 to 0.95, P = 0.023) were associated with worse adherence.

CONCLUSIONS

Increased self-reported ART adherence in Myanmar is associated with less enacted and internalized stigma. These findings suggest the benefit of developing and promoting adherence interventions, which are focused on mitigating HIV-related stigma in the county.

It Cannot Happen, Never: A Qualitative Study Exploring Youth Views on Disclosure of HIV Diagnosis to Their Sexual Partners in Southern Malawi

ABSTRACT

With the availability of antiretroviral therapy, more children living with HIV live longer than before and grow into young adulthood. This study examined the concerns of youth about disclosure of an HIV diagnosis to their sexual partners and attempted to gain an understanding of their HIV status disclosure experiences, views, and plans. A focused ethnography was undertaken. Using semi-structured interviews, data were collected from 20 youth between the ages of 15 and 24 years who were attending an HIV clinic. The findings highlight that youth generally struggled to disclose their HIV status to their sexual partners. The most frequent reasons for concealing their HIV status was fear of relationship termination, being unmarried, and fear that their sexual partners may reveal their HIV diagnosis to the community, thereby predisposing them to stigmatization, discrimination, and prejudice. There is a need to develop and strengthen HIV disclosure support groups for youth to help them develop life skills for overcoming HIV-related stigma.

Predictors of HIV Status Disclosure to Sexual Partners Among People Living with HIV in Brazil

The objective of this study was to identify the factors associated with the non-disclosure of HIV seropositivity among people living with HIV/AIDS undergoing antiretroviral treatment. A cross-sectional study was carried out in five HIV clinics in the interior of the state of São Paulo, Brazil. Logistic regression analysis was used to determine independent predictors of HIV status disclosure. It was found that 68.5% revealed their HIV seropositivity to their most recent sexual partner. The variables "casual partner" [OR 19.08, 95% CI (4.08, 20.23), p = 0.001], "sexual partners with negative HIV or unknown HIV" [OR 4.54, 95% CI (1.58, 1.01), p = 0.005], "multiple sexual partners" [OR = 3.17, 95% CI (1.34, 7.35), p = 0.009], and "lack of communication with the partner on HIV prevention"[OR = 8.3, 95% CI (3.88, 16.61), p = 0.001] were independently associated with non-disclosure of the diagnosis. Future HIV prevention interventions should encourage open communication between sexual partners.

Classifying stigma experience of women living with HIV in Indonesia through the social ecological model

Little is known how stigma theories apply to women living with HIV (WLWH). To apply stigma theories to WLWH, and locate within the dimensions of the Social-Ecological Model (SEM). Using a literature review and a theoretical subtraction to apply stigma forms to the SEM dimensions. WLWH begin to self-stigmatize, receive stigma based on fear from the family and community. Healthcare providers and society stigmatize WLWH by ascribing character flaws to them. The SEM allowed us to locate the dimensions of stigma and identify areas for future interventions for WLWH in Indonesia and other countries.

Dimensions of HIV-related stigma in rural communities in Kenya and Uganda at the start of a large HIV 'test and treat' trial

HIV-related stigma is a frequently cited barrier to HIV testing and care engagement. A nuanced understanding of HIV-related stigma is critical for developing stigma-reduction interventions to optimize HIV-related outcomes. This qualitative study documented HIV-related stigma across eight communities in east Africa during the baseline year of a large HIV test-and-treat trial (SEARCH, NCT: 01864603), prior to implementation of widespread community HIV testing campaigns and efforts to link individuals with HIV to care and treatment. Findings revealed experiences of enacted, internalized and anticipated stigma that were highly gendered, and more pronounced in communities with lower HIV prevalence; women, overwhelmingly, both held and were targets of stigmatizing attitudes about HIV. Past experiences with enacted stigma included acts of segregation, verbal discrimination, physical violence, humiliation and rejection. Narratives among women, in particular, revealed acute internalized stigma including feelings of worthlessness, shame, embarrassment, and these resulted in anxiety and depression, including suicidality among a small number of women. Anticipated stigma included fears of marital dissolution, verbal and physical abuse, gossip and public ridicule. Anticipated stigma was especially salient for women who held internalized stigma and who had experienced enacted stigma from their partners. Anticipated stigma led to care avoidance, care-seeking at remote facilities, and hiding of HIV medications. Interventions aimed at reducing individual and community-level forms of stigma may be needed to improve the lives of PLHIV and fully realize the promise of test-and-treat strategies.

Attrition in HIV care following HIV diagnosis: a comparison of the pre-UTT and UTT eras in South Africa

INTRODUCTION

Policies for Universal Test & Treat (UTT) and same-day initiation (SDI) of antiretroviral therapy (ART) were instituted in South Africa in September 2016 and 2017 respectively. However, there is limited evidence on whether these changes have improved patient retention after HIV diagnosis.

METHODS

We enrolled three cohorts of newly diagnosed HIV-infected adults from two primary health clinics in Johannesburg from April to November 2015 (Pre-UTT, N = 144), May-September 2017 (UTT, N = 178) and October-December 2017 (SDI, N = 88). A baseline survey was administered immediately after HIV diagnosis after which follow-up using clinical records (paper charts, electronic health records and laboratory data) ensued for 12 months. The primary outcome was patient loss to follow-up (being >90 days late for the last scheduled appointment) at 12 months post-HIV diagnosis. We modelled attrition across HIV policy periods with Cox proportional hazard regression.

RESULTS

Overall, 410 of 580 screened HIV-positive patients were enrolled. Overall, attrition at 12 months was 30% lower in the UTT guideline period (38.2%) compared to pre-UTT (47.2%, aHR 0.7, 95% CI: 0.5 to 1.0). However, the total attrition was similar between the SDI (47.7%) and pre-UTT cohorts (aHR 1.0, 95% CI: 0.7 to 1.5). Older age at HIV diagnosis (aHR 0.5 for ≥40 vs. 25 to 29 years, 95% CI: 0.3 to 0.8) and being in a non-marital relationship (aHR 0.5 vs. being single, 95% CI: 0.3 to 0.8) protected against LTFU at 12 months, whereas LTFU rates increased with longer travel time to the diagnosing clinic (aHR 1.8 for ≥30 minutes vs. ≤15 minutes, 95% CI: 1.1 to 3.1). In analyses adjusted for the time-varying ART initiation status, compared to the pre-ART period of care, the hazard of on-ART LTFU was 90% higher among participants diagnosed under the SDI policy compared to pre-UTT (aHR 1.9, 95% CI: 1.1 to 2.9).

CONCLUSIONS

Overall, nearly two-fifths of HIV positive patients are likely to disengage from care by 12 months after HIV diagnosis under the new SDI policy. Furthermore, the increase in on-ART patient attrition after the introduction of the SDI policy is cause for concern. Further research is needed to determine the best way for rapidly initiating patients on ART and also reducing long-term attrition from care.

Translation and validation of the Short HIV Stigma scale in Brazilian Portuguese

BACKGROUND

HIV-related stigma, or the degree to which people living with HIV endorse negative stereotypes associated with HIV, is associated with poor continuum of care outcomes. We translated the 12-item Short HIV Stigma scale and evaluated its psychometric properties in a Brazilian context with regard to construct validity and reliability.

METHODS

The first step included translation, back-translation, evaluation, peer review, and pre-testing of the Short HIV Sigma scale developed by Reinius et al. (Health Qual Life Outcomes 15(1):115, 2017). The second step involved piloting the scale in three convenience samples of adults recruited online through advertisements on different platforms: Grindr (October/2019) and Hornet (February-March/2020), geospatial network apps for sexual encounters for gay, bisexuals and other men who have sex with men, and social media apps (Facebook and WhatsApp, October/2019). The psychometric evaluation included confirmatory factor analysis, differential item functioning using the Multiple-Indicator Multiple-Cause model, and correlations between subscale scores and antiretroviral treatment use and adherence. Reliability was assessed using Cronbach's alpha, and ordinal alpha and omega from the polychoric correlation matrix.

RESULTS

In total, 114, 164, and 1824 participants completed the measure items through Grindr, social media, and Hornet, respectively. We confirmed a 4-factor structure with factors for personalized stigma (3 items), disclosure concerns (3 items), concerns with public attitudes (3 items), and negative self-image (3 items). Small differential item functioning with respect to sample was found for one item ("I feel guilty because I have HIV"), which did not substantively influence estimates of latent factor scores. Grindr and Hornet's participants scored significantly higher than social media participants on all factors except personalized stigma. Higher subscale scores correlated with antiretroviral treatment use among participants from Hornet and with lower treatment adherence in participants from Grindr and Hornet. Reliability as measured by Cronbach's alpha, ordinal alpha and omega were 0.83, 0.88 and 0.93 for the entire scale.

DISCUSSION

The Brazilian Portuguese version of the Short HIV Stigma scale had satisfactory psychometric properties with present results suggesting that scores from different samples may be compared without concern that measurement differences substantively influence results though further studies with greater representation of women and heterosexual men are warranted.

The invisible intersectionality of female gender in Thailand's response to the HIV epidemic

This article uses feminist perspectives to analyse Thailand's response to the HIV epidemic from its inception in 1984 until today. In particular, it applies the WHO Gender Responsiveness Assessment Scale to explain how and to what degree gender considerations have been integrated into successive HIV policies and programmes. Findings show that, from 1984 to 1996, HIV prevention policies were generally insensitive to gender and only started to pay limited attention to women's needs between 1997 and 2011. Gender sensitivity increased in the 2012-2019 period, but the focus then was more on 'men who have sex with men' and the transgender communities than on women. In general, Thailand's HIV responses has overlooked gender power relations and the adverse effects of the intersection between women's gender and their other disadvantaged social statuses.

Do Sexual Partners Talk to Each Other About HIV? Exploring Factors Associated with HIV-Related Partner Communication Among Men and Women in Tanzania

Communication between sexual partners is an important component of HIV prevention and occurs within a broader context of socio-culturally defined gender norms and dynamics. We analyzed cross-sectional data from a community-based random sample of men and women living in Kisarawe, Tanzania to understand factors related to partner communication about HIV. Bivariate and multivariate logistic regression analyses, disaggregated by gender, included variables at the individual-, relational-, and community-levels. Individuals who knew their HIV-positive status prior to the study were excluded as the focus was on risk communication, not HIV status disclosure. Of 524 participants, 129 women (43.3%) and 96 men (42.5%) reported HIV-related communication with their most recent sexual partner. For women but not men, individual-level socioeconomic factors-including education, possession of a household radio, and employment-and relational-level factors-including partner age and type-were significantly associated with partner communication. At the community level, being socially engaged was positively correlated with partner communication across genders (aOR = 2.02, 95% CI 1.05-3.89, p = 0.03 for men and aOR = 1.74, 95% CI 1.03-2.95, p = 0.04 for women). For women, having less discriminatory attitudes toward people living with HIV and favorable perceived norms of HIV-related communication were significantly associated with partner communication. For men, agreeing that women should be allowed to work outside the home was significantly correlated with partner communication (aOR = 6.02, 95% CI 2.23-16.24, p < 0.001). Findings suggest a link between gender dynamics and partner communication, with individual and relational factors being associated with communication for women and community-level factors being associated with communication for both genders.

HIV Sero-Status Non-disclosure Among HIV-Infected Opioid-Dependent Individuals: The Roles of HIV-Related Stigma, Risk Behavior, and Social Support

HIV sero-status disclosure among people living with HIV (PLWH) is an important component of preventing HIV transmission to sexual partners. Due to various social, structural, and behavioral challenges, however, many HIV-infected opioid-dependent patients do not disclose their HIV status to all sexual partners. In this analysis, we therefore examined non-disclosure practices and correlates of non-disclosure among high-risk HIV-infected opioid-dependent individuals. HIV-infected opioid-dependent individuals who reported HIV-risk behaviors were enrolled (N = 133) and assessed for HIV disclosure, risk behaviors, health status, antiretroviral therapy (ART) adherence, HIV stigma, social support and other characteristics. Multivariable logistic regression was used to identify significant correlates of non-disclosure. Overall, 23% reported not disclosing their HIV status to sexual partners, who also had high levels of HIV risk: sharing of injection equipment (70.5%) and inconsistent condom use (93.5%). Independent correlates of HIV non-disclosure included: being virally suppressed (aOR 0.19, p = 0.04), high HIV-related stigma (aOR 2.37, p = 0.03), and having multiple sex partners (aOR 5.87, p = 0.04). Furthermore, a significant interaction between HIV-related stigma and living with family/friends suggests that those living with family/friends were more likely to report not disclosing their HIV status when higher levels of perceived stigma was present. Our findings support the need for future interventions to better address the impact of perceived stigma and HIV disclosure as it relates to risk behaviors among opioid-dependents patients in substance abuse treatment settings.

HIV seroconcordance among heterosexual couples in rural KwaZulu-Natal, South Africa: a population-based analysis

INTRODUCTION

High levels of HIV seroconcordance at the population level reduce the potential for effective HIV transmission. However, the level of HIV seroconcordance is largely unknown among heterosexual couples in sub-Saharan Africa. We aimed to quantify the population level HIV seroconcordance in stable heterosexual couples in rural South Africa.

METHODS

We followed adults (≥15 years old) using a population-based, longitudinal and open surveillance system in KwaZulu-Natal, South Africa, from 2003 to 2016. Sexual partnerships and HIV status were confirmed via household surveys and annual HIV surveillance. We calculated the proportions of HIV seroconcordance and serodiscordance in stable sexual partnerships and compared them to the expected proportions under the assumption of random mixing using individual-based microsimulation models. Among unpartnered individuals, we estimated the incidence rates and hazard of sexual partnership formation with HIV-positive or HIV-negative partners by participants' own time-varying HIV status. Competing risks survival regressions were fitted adjusting for sociodemographic and clinical factors. We also calculated Newman's assortativity coefficients.

RESULTS

A total of 18,341 HIV-negative and 11,361 HIV-positive individuals contributed 154,469 person-years (PY) of follow-up. Overall, 28% of the participants were in stable sexual partnerships. Of the 677 newly formed stable sexual partnerships, 7.7% (95% CI: 5.8 to 10.0) were HIV-positive seroconcordant (i.e. both individuals in the partnership were HIV-positive), which was three times higher than the expected proportion (2.3%) in microsimulation models based on random mixing. The incidence rates of sexual partnership formation were 0.54/1000PY with HIV-positive, 1.12/1000PY with HIV-negative and 2.65/1000PY with unknown serostatus partners. HIV-positive individuals had 2.39 (95% CI: 1.43 to 3.99) times higher hazard of forming a sexual partnership with an HIV-positive partner than did HIV-negative individuals after adjusting for age, opposite-sex HIV prevalence (by 5-years age groups), HIV prevalence in the surrounding community, ART coverage and other sociodemographic factors. Similarly, forming a sexual partnership with an HIV-negative partner was 1.47 (95% CI: 1.01 to 2.14) times higher in HIV-negative individuals in the adjusted model. Newman's coefficient also showed that assortativity by participant and partner HIV status was moderate (r = 0.35).

CONCLUSIONS

A high degree of population level HIV seroconcordance (both positive and negative) was observed at the time of forming new sexual partnerships. Understanding factors driving these patterns may help the development of strategies to bring the HIV epidemic under control.

Factors influencing HIV risk-taking behaviours amongst textile factory workers living with HIV in Lesotho

With its number of employees ranging from 45,310 to 46,000, the textile and apparel industry is the main private sector employer of labour in Lesotho. It has been reported that a third (an estimated 34%) of these workers are living with HIV. There is perception that textile factory workers living with HIV (TFWLWH) in Lesotho indulge in HIV risk-taking behaviours. However, no study has yet investigated or documented factors that influence risk-taking behaviours amongst these workers. Transmitting the disease to others, treatment complications and death consequent to HIV reinfection are complications associated with HIV risk-taking behaviours by seropositive individuals. Using an in-depth, face-to-face, semi-structured interview, this study obtained the perspectives of ten factory workers from three randomly selected textile factories in Maseru, Lesotho on factors that influence HIV-risk taking behaviour amongst TFWLWH in Lesotho. Analysis of the comments given by workers revealed four core themes, namely, peer pressure, communication, cultural norms and societal norms. Determining the predictors of HIV risk-taking behaviours amongst these workers will inform both present and future interventions aimed at supporting textile factory workers living with HIV in Lesotho. This supports the need for continued research to identify HIV risk-taking behaviours by people living with HIV countrywide, to decrease the incidence of new infections and complications arising from reinfection.

Community perceptions and personal accounts of HIV discordance in rural western Kenya

Among HIV-discordant couples, the literature is sparse regarding issues related to stigma, relationships and coping. Objectives were to explore: 1) perceptions about discordant HIV status; 2) understanding of HIV discordancy; 3) effects of discordancy on couples; and 4) adaptation and coping strategies for discordant HIV status. A survey was administered to 202 members of heterosexual discordant couples in rural western Kenya. In addition, to understand the community perspective, in-depth interviews (IDI) (n = 26) and focus group discussions (FGD) (n = 10) were conducted with community opinion leaders, healthcare workers and members of discordant couples. More than 70% of men (73.4%) and women (80.4%) surveyed agreed that their relationship changed for the worse when they disclosed their HIV status to their partner. Participants of IDIs and FGDs provided several explanations for discordancy including the perception that discordancy is a lie, the negative partner has "thick blood", HIV infection is a punishment for sexual promiscuity or cultural disobedience, and that HIV is a punishment from God. Members of discordant couples reported experiencing tension and fear, stigma and rejection, and changes in partner support. Adaptation and coping strategies included counselling, sero-sorting and pursuing concordancy with the uninfected partner. HIV discordancy in a relationship can potentially cause long-term negative emotional and physical consequences. There is an acute need to develop and disseminate locally sensitive HIV-discordant couple counselling messages, and to provide couple-centred HIV care and treatment. Communication can help couples rebuild and rebalance their relationship and adjust to a new normal.

A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries

BACKGROUND

Stigma is associated with health conditions that drive disease burden in low- and middle-income countries (LMICs), including HIV, tuberculosis, mental health problems, epilepsy, and substance use disorders. However, the literature discussing the relationship between stigma and health outcomes is largely fragmented within disease-specific siloes, thus limiting the identification of common moderators or mechanisms through which stigma potentiates adverse health outcomes as well as the development of broadly relevant stigma mitigation interventions.

METHODS

We conducted a scoping review to provide a critical overview of the breadth of research on stigma for each of the five aforementioned conditions in LMICs, including their methodological strengths and limitations.

RESULTS

Across the range of diseases and disorders studied, stigma is associated with poor health outcomes, including help- and treatment-seeking behaviors. Common methodological limitations include a lack of prospective studies, non-representative samples resulting in limited generalizability, and a dearth of data on mediators and moderators of the relationship between stigma and health outcomes.

CONCLUSIONS

Implementing effective stigma mitigation interventions at scale necessitates transdisciplinary longitudinal studies that examine how stigma potentiates the risk for adverse outcomes for high-burden health conditions in community-based samples in LMICs.

The Role of Religious Service Attendance, Psychosocial and Behavioral Determinants of Antiretroviral Therapy (ART) Adherence: Results from HPTN 063 Cohort Study

Early and sustained antiretroviral therapy (ART) adherence can suppress the HIV virus in individuals and reduce onward transmission of HIV in the population. Religiosity has been associated with better HIV clinical outcomes. Data are from a longitudinal, observational study of 749 HIV-infected individuals from Brazil, Zambia, and Thailand (HPTN 063). Ordered logistic regression assessed whether religious service attendance was associated with ART adherence (self-reported and plasma HIV-RNA) and moderated the association between alcohol problems and ART adherence. In each country, > 80% of participants reported high self-reported ART adherence (good/very good/excellent). Religious service attendance exceeded 85% but was statistically unrelated to adherence. In combined-country models, (p = 0.03) as alcohol problems increased, the probability of high self-reported ART adherence, as well as viral-load, became weaker at higher compared to low service attendance frequency. Future studies should evaluate spirituality variables and replicate the moderation analyses between religious attendance and alcohol problems.

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

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

HIV-status disclosure and depression in the context of unintended pregnancy among South African women

Depressive symptoms are common among pregnant women living with HIV, and an unintended pregnancy may heighten vulnerability. HIV-status disclosure is thought to improve psychological well-being, but few quantitative studies have explored the relationships among disclosure, pregnancy intention and depression. Using multivariable linear regression models, we examined the impact of disclosure on depressive symptoms (Edinburgh Postnatal Depression Scale; EPDS) during pregnancy and postpartum among women who tested HIV-positive during the pregnancy in South Africa; and explored the role of pregnancy intention in this relationship. Among 350 women (median age: 27 years; 70% reporting that their current pregnancy was unintended), neither disclosure to a male partner nor disclosure to ≥1 family/community member had a consistent effect on depressive symptoms. However, pregnancy intention modified the association between disclosure to a male partner and depression during pregnancy: disclosure was associated with higher depression scores among women who reported that their current pregnancy was unintended but was associated with lower depression scores among women who reported that their pregnancy was intended. During the early postpartum period, disclosure to ≥1 family/community member was associated with higher depression scores. Counselling around disclosure in pregnancy should consider the heightened vulnerability that women face when experiencing an unintended pregnancy.

Pathways From HIV-Related Stigma to Antiretroviral Therapy Measures in the HIV Care Cascade for Women Living With HIV in Canada

BACKGROUND

Associations between HIV-related stigma and reduced antiretroviral therapy (ART) adherence are widely established, yet the mechanisms accounting for this relationship are underexplored. There has been less attention to HIV-related stigma and its associations with ART initiation and current ART use. We examined pathways from HIV-related stigma to ART initiation, current ART use, and ART adherence among women living with HIV in Canada.

METHODS

We used baseline survey data from a national cohort of women living with HIV in Canada (n = 1425). Structural equation modeling using weighted least squares estimation methods was conducted to test the direct effects of HIV-related stigma dimensions (personalized, negative self-image, and public attitudes) on ART initiation, current ART use, and 90% ART adherence, and indirect effects through depression and HIV disclosure concerns, adjusting for sociodemographic factors.

RESULTS

In the final model, the direct paths from personalized stigma to ART initiation (β = -0.104, P < 0.05) and current ART use (β = -0.142, P < 0.01), and negative self-image to ART initiation (β = -0.113, P < 0.01) were significant, accounting for the mediation effects of depression and HIV disclosure concerns. Depression mediated the pathways from personalized stigma to ART adherence, and negative self-image to current ART use and ART adherence. Final model fit indices suggest that the model fit the data well [χ(25) = 90.251, P < 0.001; comparative fit index = 0.945; root-mean-square error of approximation = 0.044].

CONCLUSIONS

HIV-related stigma is associated with reduced likelihood of ART initiation and current ART use, and suboptimal ART adherence. To optimize the benefit of ART among women living with HIV, interventions should reduce HIV-related stigma and address depression.

The role of social support in the association between childhood trauma and depression among HIV-infected and HIV-uninfected individuals

Childhood trauma (CT) - emotional, physical or sexual abuse, or emotional or physical neglect - has been associated with HIV infection and can lead to poor health outcomes and depression in adulthood. Though the impact of CT on depression may be decreased by social support, this may not be true of individuals living with HIV, due to the additive traumatic effects of both CT and acquisition of HIV. This study examined social support, depression, and CT among HIV-infected (n = 134) and HIV-uninfected (n = 306) men and women. Participants (N = 440) were assessed regarding sociodemographic characteristics, CT, depression, and social support. Participants were racially and ethnically diverse, 36 ± 9 years of age on average, and 44% had an income of less than USD$500 a month. Among HIV-uninfected individuals, social support explained the association between depression in persons with CT ( b = 0.082, bCI [0.044, 0.130]). Among HIV-infected individuals, after accounting for sociodemographic characteristics, social support did not explain the association between depression and CT due to lower levels of social support among HIV-infected individuals [95% CI: -0.006, 0.265]. The quality of social support may differ among HIV-infected persons due to decreased social support and smaller social networks among those living with HIV. Depressive symptoms among those living with HIV appear to be less influenced by social support, likely due to the additive effects of HIV infection combined with CT.

Recruitment of Underrepresented Minority Researchers into HIV Prevention Research: The HIV Prevention Trials Network Scholars Program

Most U.S. investigators in the HIV Prevention Trials Network (HPTN) have been of majority race/ethnicity and sexual orientation. Research participants, in contrast, have been disproportionately from racial/ethnic minorities and men who have sex with men (MSM), reflecting the U.S. epidemic. We initiated and subsequently evaluated the HPTN Scholars Program that mentors early career investigators from underrepresented minority groups. Scholars were affiliated with the HPTN for 12-18 months, mentored by a senior researcher to analyze HPTN study data. Participation in scientific committees, trainings, protocol teams, and advisory groups was facilitated, followed by evaluative exit surveys. Twenty-six trainees have produced 17 peer-reviewed articles to date. Research topics typically explored health disparities and HIV prevention among black and Hispanic MSM and at-risk black women. Most scholars (81% in the first five cohorts) continued HIV research after program completion. Alumni reported program-related career benefits and subsequent funding successes. Their feedback also suggested that we must improve the scholars' abilities to engage new research protocols that are developed within the network. Mentored engagement can nurture the professional development of young researchers from racial/ethnic and sexual minority communities. Minority scientists can benefit from training and mentoring within research consortia, whereas the network research benefits from perspectives of underrepresented minority scientists.

HIV status disclosure, facility-based delivery and postpartum retention of mothers in a prevention clinical trial in rural Nigeria

Background

Within the context of a cluster randomized prevention of mother-to-child HIV transmission (PMTCT) trial, we evaluated the impact of disclosure on selected PMTCT continuum of care measures.

Methods

In 12 rural matched-pair clinics randomly assigned to an intervention package versus standard-of-care, we enrolled 372 HIV-infected pregnant women from April 2013 to March 2014. This secondary analysis included 327 (87.9%) women with unknown HIV status or who were treatment naïve at presentation to antenatal care. We employed mixed effects logistic regression to estimate impact of disclosure on facility delivery and postpartum retention in HIV care at 6 and 12 weeks.

Results

Fully 86.5% (283/327) of women disclosed their HIV status to their partner, more in the trial intervention arm (OR 3.17, 95% CI 1.39-7.23). Adjusting for intervention arm, maternal age, education and employment, women who disclosed were more likely to deliver at a health facility (OR 2.73, 95%CI 1.11-6.72). Participants who disclosed also had a trend towards being retained in care at 6 and 12 weeks' postpartum (OR 2.72, 95% CI 0.79-9.41 and 2.46, 95% CI 0.70-8.63, respectively).

Conclusions

HIV status disclosure at 6 weeks' postpartum was positively associated with facility-based delivery, but not with early postpartum retention. Facilitating HIV status disclosure to partners can increase utilization of facility obstetric services.

"…like because you are a grownup, you do not need help": Experiences of Transition from Pediatric to Adult Care among Youth with Perinatal HIV Infection, Their Caregivers, and Health Care Providers in the Dominican Republic

With the introduction of combination antiretroviral therapy (ART) worldwide, youth with perinatal HIV infection are increasingly surviving childhood and transitioning to adult care. Although a normal life span is anticipated posttransition, successful transition to adult HIV care has proven difficult, with worse outcomes posttransition than in pediatric and adult care. This study is a qualitative analysis of data from 4 focus groups of pre- and posttransition patients, caregivers, and healthcare providers in the Dominican Republic at an institution that provides comprehensive treatment including ART for HIV-infected persons of all ages. All groups discussed the problems and challenges that patients, caregivers, and providers experience while living the transition process and beyond. Five major themes emerged: the trauma of transition itself, ART adherence, experience and impact of stigma, social supports and barriers, and recommendations for improving outcomes. Participants' insights offered approaches for a versatile structured transition process.

HIV-related stigma in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada

HIV-related stigma is associated with many psychological challenges; however, minimal research has explored how perceived HIV-related stigma intersects with psychosocial issues that mothers living with HIV may experience including depression, perceived stress and social isolation. The present study aims to describe the correlates and predictors of HIV-related stigma in a cohort of women living with HIV (WLWH) from across Ontario, Canada during pregnancy and early postpartum. From March 2011 to December 2012, WLWH ≥ 18 years (n = 77) completed a study instrument measuring independent variables including sociodemographic characteristics, perceived stress, depression symptoms, social isolation, social support and perceived racism in the third trimester and 3, 6 and 12 months postpartum. Multivariable linear regression was employed to explore the relationship between HIV-related stigma and multiple independent variables. HIV-related stigma generally increased from pregnancy to postpartum; however, there were no significant differences in HIV-related stigma across all study time points. In multivariable regression, depression symptoms and perceived racism were significant predictors of overall HIV-related stigma from pregnancy to postpartum. The present analysis contributes to our understanding of HIV-related stigma throughout the pregnancy-motherhood trajectory for WLWH including the interactional relationship between HIV-related stigma and other psychosocial variables, most notably, depression and racism.

Community Cultural Norms, Stigma and Disclosure to Sexual Partners among Women Living with HIV in Thailand, Brazil and Zambia (HPTN 063)

BACKGROUND

Serostatus disclosure may facilitate decreased HIV transmission between serodiscordant partners by raising risk awareness and heightening the need for prevention. For women living with HIV (WLWH), the decision to disclose may be influenced by culturally determined, community-level stigma and norms. Understanding the impact of community HIV stigma and gender norms on disclosure among WLWH in different countries may inform intervention development.

METHODS

HPTN063 was a longitudinal, observational study of sexually active HIV-infected individuals, including heterosexual women, in care in Zambia, Thailand and Brazil. At baseline, a questionnaire measuring community HIV stigma and gender norms, anticipated stigma, demographic, partner/relationship characteristics, and intimate partner violence was administered. Longitudinal HIV disclosure to sexual partners was determined via audio-computer assisted self-interview (ACASI) at the baseline and quarterly during the one year following up. Logistic regression was conducted to identify the predictors of disclosure.

RESULTS

Almost half (45%) of women living with HIV acknowledged perceived community HIV stigma (the belief that in their community HIV infection among women is associated with sex work and multiple sexual partners). Many women (42.9%) also acknowledged perceived community gender norms (the belief that traditional gender norms such as submissiveness to husbands/male sexual partners is necessary and that social status is lost if one does not procreate). HIV disclosure to current sex partners was reported by 67% of women. In multivariate analysis, among all women, those who were older [OR 0.16, 95%CI(0.06,0.48)], reported symptoms of severe depression [OR 0.53, 95%CI(0.31, 0.90)], endorsed anticipated stigma [OR 0.30, 95%CI(0.18, 0.50)], and were unmarried [OR 0.43, 95%CI(0.26,0.71)] were less likely to disclose to current partners. In an analysis stratified by marital status and cohabitation, unmarried [OR 0.41, 95%CI(0.20,0.82)] and non-cohabiting women [OR 0.31, 95%CI(0.13,0.73)] who perceived community HIV stigma were less likely to disclose to their sex partners.

CONCLUSIONS

Perceived community level HIV stigma, along with individual level factors such as anticipated stigma, depressive symptoms, and older age, predict non-disclosure of HIV status to sexual partners among WLWH in diverse geographic settings. Interventions to promote disclosure among women in serodiscordant relationships should incorporate community-level interventions to reduce stigma and promote gender equality.