Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: A qualitative study

A conceptualization and psychometric evaluation of positive psychological outcome measures used in adolescents and young adults living with HIV: A mixed scoping and systematic review

INTRODUCTION

Sub-Saharan Africa bears the greatest burden of HIV, with comorbid mental conditions highly prevalent in people living with HIV. It is important to evaluate the mental health of adolescents and young adults living with HIV (AYALHIV) comprehensively by measuring both negative and positive psychological constructs. There has been a proliferation of interest in positive psychological outcome measures, but the evidence of their psychometric robustness is fragmented. This review sought to: 1) Identify positive psychological outcomes and corresponding outcome measures used in AYALHIV in sub-Saharan Africa. 2) Critically appraise the psychometrics of the identified outcome measures.

METHODS AND ANALYSIS

Two reviewers independently searched articles in PubMed, Scopus, Africa-Wide Information, CINAHL, Psych INFO and Google Scholar. Searches were conducted from November 2022 to February 2023. Two separate reviewers independently reviewed retrieved articles. We applied a narrative synthesis to map the key constructs. The risk of bias across studies was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The quality of the psychometric properties was rated using the COSMIN checklist and qualitatively synthesized using the modified Grading of Recommendations Assessment, Development, and Evaluation checklist.

RESULTS

We identified 15 positive psychological constructs: body appreciation, confidence, coping, flourishing, meaningfulness, personal control, positive outlook, resilience, self-management, self-compassion, self-concept, self-efficacy, self-esteem, self-worth and transcendence, that had been used to assess ALHIV. The most measured constructs were resilience, self-concept, self-esteem, coping and self-efficacy. Construct validity and internal consistency were the properties most frequently considered, while content validity and structural validity were assessed less often.

CONCLUSIONS

Few studies performed complete validations; thus, evidence for psychometric robustness was fragmented. However, this review shows the initial evidence of the feasibility of using positive psychological outcomes in low-resource settings. Instead of creating new outcome measures, researchers are recommended to leverage the existing measures, adapt them for use and, if appropriate, strive to maintain the factorial structure to facilitate comparisons.

REGISTRATION

PROSPERO-CRD42022325172.

How Mobile Health Can Change the Contexts of Living With HIV and Engaging With Treatment and Care in Iran: A Realist-Informed Qualitative Study

Mobile health (mHealth) interventions are increasingly used to address the challenges of living with HIV and engaging with antiretroviral therapy. A wealth of evidence supports the efficacy of mHealth in supporting living with HIV. Yet, there is a dearth of evidence on how mHealth improves outcomes, which features are effective, and why these work in a particular setting. This study uses stakeholder views, including patients, providers, peer supporters, counsellors, and program directors, to conceptualize how specific mHealth features could interact with contexts of living with HIV and mechanisms that shape engagement with treatment. The study is part of an ongoing research project on engagement with HIV care in Iran. We draw on the perspectives of recently diagnosed and more treatment-experienced patients and their providers, using purposive sampling, conducting 9 focus group discussions with a total of 66 participants, in addition to 17 interviews. Our findings suggest that mHealth designs that feature provider connection, proactive care, and privacy and personalization are expected to dilute the harsh contexts of living with HIV. We build on previously identified socioecological pathways that disrupt antiretroviral therapy in Iran and find that mHealth can enhance the relation between the health system and patients. Our findings suggest that personalized mHealth features and provisions can partially mitigate the compounded impacts of harsh socioecological pathways that impede treatment success in Iran. Our social constructivist study was augmented with realist-informed analysis and could have transferability to similar contexts that trigger similar mechanisms of treatment disruption.

Understanding the Stigma Experience of Men Living with HIV in Sub-Saharan Africa: A Qualitative Meta-synthesis

Men living with HIV (MLWH) in sub-Saharan Africa experience poor health outcomes and increased AIDS-related deaths due to stigma influencing testing and treatment uptake and adherence. PRISMA 2020 was used to report a meta-synthesis of the stigma experiences of MLWH in SSA. With the help of an expert librarian, a search of six databases was formulated and performed to examine the available qualitative and mixed method studies with qualitative results relevant to the research question. Studies focused on adult men living with HIV, with five studies specifically examining the HIV experience of men who have sex with men. Study themes were synthesized to describe MLWH's perceived, internalized, anticipated, enacted, and intersectional stigma experiences. Most studies included masculinity as a key theme that affected both testing and treatment adherence upon diagnosis. Future research is needed to better understand subpopulations, such as men who have sex with men living with HIV, and what interventions may be beneficial to mitigate the disparities among MLWH in SSA.

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

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

Physician-Patient Interaction Quality Mediates the Association Between HIV-Related Stigma and HIV-Prevention Behaviors Among Sexual Minority Men in Zambia

HIV-related stigma is a major challenge to HIV prevention for sexual minority men (SMM) in Zambia, but little is known about the underlying mechanisms. This study aimed to investigate whether physician-patient interaction quality mediates the relationship between HIV-related stigma and HIV-prevention behaviors among SMM. Data were collected using a cross-sectional survey from 194 SMM (aged: mean = 24.08, SD = 4.27) across four districts in Zambia between February and November 2021. Participants were asked about their demographic characteristics, HIV-related stigma, SMM-related stigma, physician-patient interaction quality, HIV-testing intention, and use of pre-exposure prophylaxis (PrEP). Path analysis was used to test the mediation effect of physician-patient interaction quality in the associations of HIV-related stigma/SMM-related stigma with HIV-testing intention and current PrEP use. Higher self-reported physician-patient interaction quality was negatively associated with HIV-related stigma (β = - 0.444, z = - 2.223, p < 0.05), and positively associated with HIV-testing intention (β = 0.039, z = 5.121, p < 0.001) and current PrEP use (β = 0.008, z = 2.723, p < 0.01). HIV-related stigma among SMM had a significant and negative indirect effect on HIV-testing intention (β = - 0.017, z = - 2.006, p < 0.05), and current PrEP use (β = - 0.004, z = - 2.009, p < 0.05) through physician-patient interaction quality. Contrary to our expectations, SMM-related stigma did not have a significant and negative indirect effect on HIV prevention behaviors through physician-patient interaction quality. Health interventions need to improve physician-patient interaction quality by offering healthcare provider training, targeting HIV-related stigma in healthcare settings, and devising inclusive healthcare policies to promote HIV prevention efforts.

"I am still human and worth a life:" a qualitative study of the impacts of a community based, peer-led, treatment support model for young adults living with HIV in Zimbabwe

Background

A persistent treatment gap remains between children and adults living with HIV. The Zvandiri program, developed by Africaid, is one of the few models of differentiated service delivery for children, adolescents, and youth that has been shown to improve outcomes along the HIV care continuum, employing Community Adolescent Treatment Supporters (CATS) to offer peer counseling and patient navigation. Our qualitative study provides an in-depth analysis of the feelings and experiences Zimbabwean youth had following an HIV diagnosis, and the ways that CATS facilitated linkage and retention in care.

Methods

We conducted in-depth interviews in Shona with adolescents and young adults who were recently diagnosed with HIV in Zimbabwe. Interviews were audio-recorded, transcribed, and then translated to English. Interviews were coded in Dedoose using a structured a priori codebook. We wrote semi-structured summary memos for each interview. We co-conducted thematic analysis, guided by interpretive phenomenology with a team of Zimbabwean and American experienced qualitative researchers and community partners. We co-developed memos to elaborate and understand key themes across interviews.

Results

Most of our interview participants recounted an immediate sense of loss upon testing HIV positive and a fear that "there was no hope for the future." CATS played a pivotal role for youth, providing emotional, educational, and logistical support to facilitate treatment initiation, adherence, and persistence in care. The CATS program supported youth through multiple approaches: group sessions, individual meetings, and via text or phone. While CATS offered counseling and comfort to participants, they emphasized the long-term importance of identifying at least one other person in participants' lives who could know their status and support them around HIV.

Conclusion

Our findings delineate some of the key concerns that face youth after receiving an HIV diagnosis and the ways that a community-based adherence peer navigation program supported participants to navigate both their feelings and the health care system. Results can inform practice at community-based agencies that are implementing or considering peer youth navigation programs and garner support for policy to fund interventions for youth.

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

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

The Moderating Role of HIV Stigma on the Relationship between Perceived Social Support and Antiretroviral Therapy Adherence Self-Efficacy among Adult PLHIV in South Africa

BACKGROUND

People living with human immune deficiency virus (PLHIV) grapple with distinct challenges, including HIV stigma which affects their antiretroviral therapy (ART) adherence self-efficacy. This study investigates the interaction of HIV stigma and perceived social support on ART adherence self-efficacy among adult PLHIV in South Africa.

METHODS

This study utilized a cross-sectional design that involved 201 participants selected using time location sampling at a tertiary health facility in Durban.

RESULTS

HIV stigma was significantly and negatively associated with self-efficacy (β = -7.860, t = -4.654, p = .001), with variations across different stigma levels (β = -5.844, t = -4.003, p = .001). Social support was significantly and positively associated with self-efficacy at lower HIV stigma levels (β = 7.440, t = 3.887, p = .001), in contrast to higher levels (β = -2.825, t = 1.400, p = .163).

CONCLUSION

Social support significantly influences ART adherence self-efficacy, particularly at lower levels of HIV stigma, but the effect of support weakens as stigma intensifies.

Health services satisfaction and medical exclusion among migrant youths in Gauteng Province of South Africa: A cross-sectional analysis of the GCRO survey (2017-2018)

BACKGROUND

Medical xenophobia of migrant (either in-migrants or immigrants) youths is an ongoing problem in contemporary South African society. Medical mistreatment by healthcare workers and social phobia from migrant youths have been attributed to major obstacles to healthcare utilization as well as health services satisfaction. This study aimed to determine the prevalence and factors contributing to health services satisfaction and medical exclusion among migrant youths in Gauteng province in South Africa.

METHODS

The Round 5 Gauteng City-Region Observatory (GCRO) Quality of Life (QoL) survey was conducted in 2017‒2018, a nationally representative survey piloted every two years in South Africa, was utilized in this study. A 2-year cohort study of 24,889 respondents aged 18 to 29 and a baseline data consisted of 4,872 respondents, comprising non-migrants, in-migrants and immigrants, from where 2,162 in-migrants and immigrants were utilized as the sample size. The data was analysed using descriptive statistics, Chi-Square analysis and logistic regression.

RESULTS

A total of 2,162 migrants, comprising 35.4% in-migrants and 9.0% of immigrants, from the 4,872 respondents, were included in the analysis. The prevalence of medical exclusion of in-migrant and immigrant youths were 5.5% and 4.2%, and the majority of them reported the use of public health facilities (in-migrants ‒ 84.3% vs. immigrants ‒ 87.1%). At the bivariate level, demographic (age, sex, and population group), economic (employed and any income) and health-related (no medical aid and household member with mental health) factors were significantly associated with medical exclusion (ρ≤0.05). The adjusted odds ratio showed that only female gender (AOR: 1.07, 95% CI: 0.678, 1.705), no medical aid cover (AOR: 1.23, 95% CI: 0.450, 3.362), and neither (AOR: 1.59, 95% CI: 0.606, 4.174) or dissatisfied (AOR: 4.29, 95% CI: 2.528, 7.270) were independent predictors of medical exclusion.

CONCLUSION

Having no medical aid cover, being a female and dissatisfied, or neither satisfied nor dissatisfied with health services significantly increased the odds of medical exclusion among migrant youths. To increase healthcare utilization and ensuring adequate medical care of migrant youths, opting for medical aid insurance without increasing costs should be guaranteed. Therefore, there should be no consequences for lack of residence status or correct documentation papers when accessing healthcare services among migrant youths in South Africa.

"We will tell when we are ready": perinatally HIV-infected adolescents and self-disclosure of their status in Eswatini

Access to antiretroviral therapy (ART) has promoted a significant decrease in mortality of vertically HIV-infected children. As a result, there has been an increasing growth of this population that reaches adolescence. These adolescents face problems such as self-disclosure and the stigma of the disease. This study aimed to determine the process followed by perinatally HIV-infected adolescents in self-disclosing their HIV status to significant others and the barriers and promoters of perinatally HIV-infected adolescents' disclosure of their HIV status to others. Data were collected from 15-19-year-old adolescents through 23 in-depth individual interviews and three focus groups. For adolescents, a clear barrier to disclosure was being told when they were younger by a parent to keep their status secret from other people. Lack of trust and fear of breaches of confidentiality which would lead to stigma and discrimination also hindered disclosure. For those adolescents who disclosed, they did so face to face and through short text messages. Adolescents expressed the need to be capacitated to self-disclose and also called for HIV and AIDS education to the general public as a way of fighting stigma and discrimination in their communities and in society. For adolescents to be able to disclose, they have to work through issues of acceptance of their own HIV status first. This study is the first-ever study to document difficulties faced by adolescents in the self-disclosure of their status in Eswatini.

Wakakosha "You are Worth it": reported impact of a community-based, peer-led HIV self-stigma intervention to improve self-worth and wellbeing among young people living with HIV in Zimbabwe

Introduction

Self-stigma-negative self-judgements or core beliefs-can result in feelings of shame, worthlessness and self-blame, and impacts social interaction, mental health and health service utilization among people living with HIV (PLHIV). Few interventions target self-stigma among PLHIV and, to our knowledge, none until now for adolescents and young people LHIV (AYPLHIV) in sub-Saharan Africa. We present qualitative findings on the perceived impact of a self-stigma intervention (Wakakosha, "You are Worth it").

Methods

The Wakakosha intervention adopted inquiry-based stress reduction (IBSR) at its core-a unique way of identifying and questioning deeply rooted self-stigma, combined with mindfulness, meditation and creativity. The intervention consisted of 16 × 3 hour group sessions. Supporting the intervention was a 156-page activity journal. We utilized a qualitative enquiry to explore the perceived impact of the intervention at various time points between November 2021 and November 2022, with 62 participants (n = 32 female). Discussions explored experiences of being involved in the intervention and any reports on changes in relation to self-stigma and shame. Additionally, we reviewed intervention documentation and creative elements. A thematic analysis guided generation of themes across all data sources.

Results

Both intervention participants and coaches described the transformative effect of the intervention, detailing their experiences before and after. Main themes that emerged were positive changes around: self-confidence, self-agency, sense of purpose/meaning, body positivity, improved communication and personal/family relationships and, forgiveness. The intervention also transferred a set of practical skills on self-inquiry, mindfulness, meditation and creativity that continued to be used in participants' daily lives.

Conclusion

The Wakakosha intervention, using IBSR supported by music, creativity, writing and mindfulness techniques, showed potential for reducing self-stigma and improving self-worth among AYPLHIV. It also transferred practical skills to intervention participants and peer coaches, building their capacity to support others and deal with life challenges beyond HIV. The next phase is to continue supporting the young people to ensure fidelity as the peer coaches deliver the intervention to others. Study results indicate that culturally and practically, interventions to reduce self-stigma and/or improve self-worth operate at various levels and need to be designed and assessed at each level.

Community Perceptions of HIV Stigma, Discriminatory Attitudes, and Disclosure Concerns: A Health Facility-Based Study in Selected Health Districts of South Africa

Research data about HIV stigma perceptions and discriminatory attitudes among the general population are limited. Furthermore, the willingness of HIV-negative individuals to engage with HIV prevention and disclosure interventions has not been established in South Africa. The study investigated community perceptions of stigma as well as discriminatory attitudes towards HIV disclosure to understand if and how these perceptions might influence the uptake of disclosure interventions. This facility-based study used a validated questionnaire to measure the four constructs of HIV stigma among 670 adults recruited from health districts of two provinces of South Africa. Of these, 72% were female, 87% had ever been tested for HIV, and 31% knew someone who has HIV. Stigma towards people living with HIV (PLHIV) is widespread in the general population. A high proportion (75%) endorsed disclosure concerns, 75% perceived stigma to be common, and 56% endorsed negative statements indicating perceived stigma in communities. Fear, moral and social judgement, and rejection underlined their perceptions about PLHIV. Almost half (45.7%) were unwilling to care for family members sick with AIDS, suggesting negative distancing reactions and discriminatory attitudes towards PLHIV. The widespread discriminatory attitudes and the perceived stigma that is evident in the general population might heighten the disclosure concerns endorsed, promote non-disclosure, and increase HIV transmission. To design interventions, it is crucial to be cognisant of disclosure concerns, discriminatory attitudes, and perceived stigma evident in communities. Thus, the findings underscore the need to increase efforts to challenge and reduce community drivers of negative discriminatory attitudes and perceived stigma.

A qualitative inquiry of experiences of HIV-related stigma and its effects among people living with HIV on treatment in rural Kilifi, Kenya

Background

The pervasiveness of HIV-related stigma and discrimination, and its consequences on HIV prevention and treatment, have been well documented. However, little is known about the lived experiences of HIV-related stigma and its effects among the general adult population living with HIV in rural African settings. This study set out to explore this knowledge gap.

Methods

From April to June 2018, we conducted in-depth interviews with a convenience sample of 40 adults living with HIV aged 18-58 years in Kilifi, Kenya. A semi-structured interview guide was used to explore experiences of HIV-related stigma and its impact on these adults. A framework approach was used to analyze the data using NVIVO 11 software.

Results

Participants reported experiences of HIV-related stigma in its various forms (anticipated, perceived, internalised, and enacted), as well as its effects on HIV treatment and social and personal spheres. The internalisation of stigma caused by enacted stigma impacted care-seeking behavior resulting in worse overall health. Anxiety and depression characterized by suicidal ideation were the results of internalised stigma. Anticipated stigma prompted HIV medication concealment, care-seeking in remote healthcare facilities, and care avoidance. Fewer social interactions and marital conflicts resulted from perceived stigma. Overall, HIV-related stigma resulted in partial and non-disclosure of HIV seropositivity and medication non-adherence. At a personal level, mental health issues and diminished sexual or marital prospects (for the unmarried) were reported.

Conclusion

Despite high awareness of HIV and AIDS among the general population in Kenya, adults living with HIV in rural Kilifi still experience different forms of HIV-related stigma (including self-stigma) that result in a raft of social, personal, and HIV-treatment-related consequences. Our findings underscore the urgent need to reevaluate and adopt more effective strategies for implementing HIV-related anti-stigma programs at the community level. Addressing individual-level stigma will require the design of targeted interventions. To improve the lives of adults living with HIV in Kilifi, the effects of HIV-related stigma, particularly on HIV treatment, must be addressed.

HIV Status Disclosure to Adolescents Who Are Perinatally Infected in Rustenburg Sub District Northwest Province

Acquired Immune Deficiency Syndrome (AIDS) is a viral disease caused by Human Immunodeficiency Virus (HIV) which affects the immune system of human body. This study sought to explore how adolescents with perinatal HIV infection learn about their status as well as investigate their preferences about the disclosure process. A qualitative exploratory, descriptive, and contextual research design was used to explore the disclosure of an HIV-positive status among adolescents on antiretroviral therapy. Nonprobability purposive sampling was used to select the healthcare facilities, and adolescents were chosen using convenience sampling. In-depth individual interviews were used to collect data from the participants until data saturation was reached. Collected data were analysed using Tesch's eight steps. The results of the study revealed that adolescents have been on ART (antiretroviral therapy) without the knowledge of their own status but taking ART. Delayed disclosure of an HIV-positive status to adolescents lead to adolescent not adhering to ART and wondering why they are on treatment while other adolescents are not. The study further revealed that parents and caregivers struggle to disclose an HIV-positive status of their children, leading them to lie about what the treatment is for, for example, that it is a treatment for cough.

Conceptualisation and psychometric evaluation of positive psychological outcome measures used in adolescents and young adults living with HIV: a mixed scoping and systematic review protocol

INTRODUCTION

Sub-Saharan Africa bears the greatest burden of HIV. Concomitant mental disorders are common, necessitating the integration of mental healthcare into routine HIV care. Consequently, it is necessary to holistically evaluate the mental health of adolescents and young adults living with HIV (AYALHIV, 10-24 years old) by measuring negative and positive psychological constructs (eg, anxiety and self-acceptance, respectively). There has been a proliferation of positive psychological outcome measures, but the evidence of their psychometric robustness is fragmented. This review, therefore, seeks to (1) identify positive psychological outcomes used in AYALHIV in sub-Saharan Africa and map the constructs onto corresponding measures and (2) critically appraise the psychometrics of the identified outcomes METHODS AND ANALYSIS: This mixed review will be done in two parts. First, a scoping review will identify positive psychological outcomes and map them onto corresponding outcome measures. Subsequently, we will systematically evaluate the psychometric properties of the outcomes identified from the scoping review. Independent and blinded reviewers will search articles in PubMed, Scopus, Web of Science, Africa-Wide Information, CINAHL, PsychINFO and Google Scholar from inception through 30 September 2022. Thereafter, separate independent reviewers will screen the retrieved articles. We will apply a narrative synthesis to map the key constructs emerging from the scoping review. For the systematic review, the risk of bias across studies will be evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The quality of the psychometric properties will be rated using the COSMIN checklist and qualitatively synthesised using the modified Grading of Recommendations Assessment, Development and Evaluation checklist.

ETHICS AND DISSEMINATION

No ethical approvals are needed. The mixed-review outputs will collectively inform the development, implementation and evaluation of bespoke interventions for AYALHIV. Review outcomes will be disseminated in a peer-reviewed journal, on social media and through policy briefs.

PROSPERO REGISTRATION

CRD42022325172.