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Wu M, Ma J, Li S, Qin S, Tan C, Xie O, Li A, Lim AG, Wan X. Effects and Costs of Hepatitis C Virus Elimination for the Whole Population in China: A Modelling Study. PHARMACOECONOMICS 2024:10.1007/s40273-024-01424-5. [PMID: 39222272 DOI: 10.1007/s40273-024-01424-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/24/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND OBJECTIVE China has the highest number of hepatitis C virus (HCV) infections in the world. However, it is unclear what levels of screening and treatment are needed to achieve the WHO 2030 hepatitis C elimination targets. We aimed to evaluate the impact of scaling up interventions on the hepatitis C epidemic and determine how and at what cost these elimination targets could be achieved for the whole population in China. METHODS We developed a compartmental model incorporating HCV transmission, disease progression, and care cascade for the whole population in China, calibrated with data on demographics, injecting drug use, HCV prevalence, and treatments. Five different scenarios were evaluated for effects and costs for 2022-2030. All costs were converted to 2021 US dollar (USD) and discounted at an annual rate of 5%. One-way sensitivity analyses were conducted to assess the robustness of the model. RESULTS Under the status quo scenario, the incidence of hepatitis C is projected to increase from 60.39 (57.60-63.45) per 100,000 person-years in 2022 to 68.72 (65.3-73.97) per 100,000 person-years in 2030, and 2.52 million (1.94-3.07 million) infected patients are projected to die between 2022 and 2030, of which 0.76 (0.61-1.08) million will die due to hepatitis C. By increasing primary screening to 10%, conducting regular rescreening (annually for PWID and every 5 years for the general population) and treating 90% of patients diagnosed, the incidence would be reduced by 88.15% (86.61-89.45%) and hepatitis C-related mortality by 60.5% (52.62-65.54%) by 2030, compared with 2015 levels. This strategy would cost USD 52.78 (USD 43.93-58.53) billion. CONCLUSIONS Without changes in HCV prevention and control policy, the disease burden of HCV in China will increase dramatically. To achieve the hepatitis C elimination targets, China needs to sufficiently scale up screening and treatment.
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Affiliation(s)
- Meiyu Wu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, 139 Renmin Rd, Changsha, 410011, Hunan, China
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, Hunan, China
| | - Jing Ma
- Department of Gastroenterology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China
| | - Sini Li
- The Nethersole School of Nursing, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Shuxia Qin
- Department of Pharmacy, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Chongqing Tan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, 139 Renmin Rd, Changsha, 410011, Hunan, China
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, Hunan, China
| | - Ouyang Xie
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, 139 Renmin Rd, Changsha, 410011, Hunan, China
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, Hunan, China
| | - Andong Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, 139 Renmin Rd, Changsha, 410011, Hunan, China
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, Hunan, China
| | - Aaron G Lim
- Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK.
- Bristol Medical School, Population Health Sciences, University of Bristol, Oakfifield House, Oakfifield Grove, Clifton, BS8 2BN, UK.
| | - Xiaomin Wan
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, 139 Renmin Rd, Changsha, 410011, Hunan, China.
- Institute of Clinical Pharmacy, Central South University, Changsha, 410011, Hunan, China.
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Rice WS, Ellison CK, Bruno B, Hussen SA, Chavez M, Nápoles TM, Walcott M, Batchelder AW, Turan B, Kempf MC, Wingood GM, Konkle-Parker DJ, Wilson TE, Johnson MO, Weiser SD, Logie CH, Turan JM, Piper K. Exploring the role of motherhood in healthcare engagement for women living with HIV in the USA. CULTURE, HEALTH & SEXUALITY 2024:1-15. [PMID: 39041302 DOI: 10.1080/13691058.2024.2380765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 07/12/2024] [Indexed: 07/24/2024]
Abstract
Mothers living with HIV are faced with managing their own complex healthcare and wellness needs while caring for their children. Understanding the lived experiences of mothers living with HIV, including grandmothers and mothers with older children - who are less explicitly represented in existing literature, may guide the development of interventions that best support them and their families. This study sought to explore the role of motherhood and related social/structural factors on engagement with HIV care, treatment-seeking behaviour, and overall HIV management among mothers living with HIV in the USA to inform such efforts. Semi-structured interviews were conducted between June and December 2015 with 52 mothers living with HIV, recruited from the Women's Interagency HIV Study (WIHS) sites in four US cities. Five broad themes were identified from the interviews: children as a motivation for optimal HIV management; children as providing logistical support for HIV care and treatment; the importance of social support for mothers; stressors tied to responsibilities of motherhood; and stigma about being a mother living with HIV. Findings underscore the importance of considering the demands of motherhood when developing more effective strategies to support mothers in managing HIV and promoting the overall health and well-being of their families.
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Affiliation(s)
- Whitney S Rice
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Celeste K Ellison
- Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Beverly Bruno
- Population Health Innovation Lab, Public Health Institute, Oakland, CA, USA
| | - Sophia A Hussen
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Max Chavez
- Population Health Innovation Lab, Public Health Institute, Oakland, CA, USA
| | - Tessa M Nápoles
- Department of Social and Behavioral Sciences, University of CA, San Francisco, CA, USA
| | - Melonie Walcott
- Lindsley F. Kimball Research Institute, NY Blood Center, New York, NY, USA
| | - Abigail W Batchelder
- Department of Psychiatry, MA General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bulent Turan
- Department of Psychology, Koc University, Istanbul, Turkey
| | - Mirjam-Colette Kempf
- Schools of Nursing, Public Health and Medicine, University of AL at Birmingham, Birmingham, AL, USA
| | - Gina M Wingood
- Department of Sociomedical Sciences, Columbia Mailman School of Public Health, New York, NY, USA
| | - Deborah J Konkle-Parker
- Medicine and Population Health Sciences, University of MS Medical Center Schools of Nursing, Jackson, MS, USA
| | - Tracey E Wilson
- Department of Community Health Sciences, SUNY Downstate Health Sciences University School of Public Health, New York, NY, USA
| | - Mallory O Johnson
- Department of Medicine, University of California, School of Medicine, San Francisco, CA, USA
| | - Sheri D Weiser
- Department of Medicine, University of California, School of Medicine, San Francisco, CA, USA
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
| | - Janet M Turan
- Department of Health Care Organization and Policy, University of Alabama at Birmingham, School of Public Health, Atlanta, GA, USA
| | - Kendra Piper
- Population Health Innovation Lab, Public Health Institute, Oakland, CA, USA
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Yang M, Zhang L, Jiang Y, Liu P, Liu W, Cao X, Luo Q, Fu C, He L. An adapted white-coat and warm-heart intervention on nurses' knowledge, general stigmatizing attitudes, and work avoidance behaviors towards HIV: a quasi-experimental study. J Occup Health 2024; 66:uiae041. [PMID: 39038083 PMCID: PMC11360590 DOI: 10.1093/joccuh/uiae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/04/2024] [Accepted: 07/18/2024] [Indexed: 07/24/2024] Open
Abstract
OBJECTIVES To determine the effect of an adapted white-coat and warm-heart intervention (AWWI) among nurses. BACKGROUND HIV discrimination among medical staff hinders progress in HIV prevention. METHODS A total of 779 nurses were randomized into intervention and control groups. The intervention group was provided with AWWI training. The control group did not receive AWWI training. HIV-related knowledge, attitudes, and behaviors of participants were assessed. RESULTS Participants in the intervention group had better HIV-related knowledge and less stigmatizing attitudes and work avoidance behavior levels than participants in the control group after the 1-, 3-, and 6-month interventions (P < .05). The main effects of group and time factors were highly significant in the intervention group. There were significant interaction effects in group and time factors. CONCLUSIONS AWWI effectively improved the level of HIV-related knowledge and reduced general stigmatizing attitudes and work avoidance behaviors among nurses based on self-reported data in a tertiary hospital in China during a 6-month period.
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Affiliation(s)
- Ming Yang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Ling Zhang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Ying Jiang
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Peng Liu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Wanli Liu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Xiaoxia Cao
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Qin Luo
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Cangmei Fu
- Department of Oncology, the Second Xiangya Hospital of Central South University, Changsha 410012, China
| | - Lianxiang He
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital of Central South University, Changsha 410008, China
- Department of Nursing, Xiangya Changde Hospital, Changde 415009, China
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Douglass CH, Win TM, Goutzamanis S, Lim MSC, Block K, Onsando G, Hellard M, Higgs P, Livingstone C, Horyniak D. Stigma Associated with Alcohol and Other Drug Use Among People from Migrant and Ethnic Minority Groups: Results from a Systematic Review of Qualitative Studies. J Immigr Minor Health 2023; 25:1402-1425. [PMID: 36976449 PMCID: PMC10632266 DOI: 10.1007/s10903-023-01468-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2023] [Indexed: 03/29/2023]
Abstract
Stigma reduces access to alcohol and other drug (AOD) support. This systematic review explored perceptions and experiences of stigma associated with AOD use among migrant and ethnic minority groups. Qualitative studies published in English were identified using six databases. Two reviewers screened and critically appraised articles using the Joanna Briggs Institute Critical Appraisal Checklist for qualitative studies. Data were synthesised using best fit framework synthesis. Twenty-three studies were included. Stigma drivers and facilitators included stereotypes, socio-cultural norms, legal responses and precarious lived experiences. Stigma intersected with gender, citizenship, race and ethnicity and manifested though shame, exclusion, secondary stigma and discrimination in treatment. Outcomes and impacts included avoidance of services, emotional distress, isolation and loneliness. This review identified similar stigma experiences to other populations, however outcomes were complicated by precarious lived experiences and multiple stigmatised identities. Multi-level interventions are required to reduce AOD-related stigma for migrant and ethnic minority groups.
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Affiliation(s)
- Caitlin H Douglass
- Burnet Institute Australia, 85 Commercial Road, Melbourne, VIC, 3004, Australia.
- Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, VIC, 3053, Australia.
| | - Thin Mar Win
- Burnet Institute Myanmar, 226 Wizaya Plaza, U Wisara Road, Yangon, Myanmar
| | | | - Megan S C Lim
- Burnet Institute Australia, 85 Commercial Road, Melbourne, VIC, 3004, Australia
- Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, VIC, 3053, Australia
- Monash School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Karen Block
- Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, VIC, 3053, Australia
| | - Gerald Onsando
- Melbourne School of Social and Political Sciences, University of Melbourne, 420 John Medley Building, Parkville, VIC, 3010, Australia
| | - Margaret Hellard
- Burnet Institute Australia, 85 Commercial Road, Melbourne, VIC, 3004, Australia
- Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, VIC, 3053, Australia
- Monash School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Peter Higgs
- Burnet Institute Australia, 85 Commercial Road, Melbourne, VIC, 3004, Australia
- Public Health Department, La Trobe University, Plenty Road, Bundoora, VIC, 3086, Australia
| | - Charles Livingstone
- Monash School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Danielle Horyniak
- Burnet Institute Australia, 85 Commercial Road, Melbourne, VIC, 3004, Australia
- Monash School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
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5
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Ferguson L, Gruskin S, Bolshakova M, Rozelle M, Yagyu S, Kasoka K, Oraro-Lawrence T, Motala A, Stackpool-Moore L, Hempel S. Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination. AIDS 2023; 37:1919-1939. [PMID: 37352492 PMCID: PMC10552822 DOI: 10.1097/qad.0000000000003628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 06/03/2023] [Accepted: 06/09/2023] [Indexed: 06/25/2023]
Abstract
A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.
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Affiliation(s)
- Laura Ferguson
- Institute on Inequalities in Global Health, University of Southern California
| | - Sofia Gruskin
- Institute on Inequalities in Global Health, University of Southern California
| | - Maria Bolshakova
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Mary Rozelle
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Sachi Yagyu
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | | | | | - Aneesa Motala
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | | | - Susanne Hempel
- Southern California Evidence Review Center, Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
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Yang JP, Shiu C, Zhang L, Wang K, Lu H, Zhao H, Chen WT. Health disparities affecting persons living with HIV and using substances in China. Appl Nurs Res 2023; 73:151729. [PMID: 37722797 PMCID: PMC10684315 DOI: 10.1016/j.apnr.2023.151729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 09/20/2023]
Abstract
Health disparities affecting persons living with HIV (PLWH) as well as those affecting individuals who use substances have been documented in China. However, health status and outcomes within the intersectional population of those who both live with HIV and use substances is not well understood. One hundred and sixty-nine PLWH receiving care in China completed surveys assessing HIV-clinical factors, substance use, and HIV-related physical health symptoms. We tested associations between substance use and health symptoms using multivariate logistic and ordinal regressions. Using one substance over the past week was associated with greater maximal severity of physical symptoms (p < .01); using two or more substances in the past week was associated with both increased total physical symptom severity (p < .05) and a dosage response in increased maximal severity (p < .01). Findings highlight the need for providers to address substance use for comprehensive care of PLWH to improve overall wellbeing.
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Affiliation(s)
- Joyce P Yang
- Department of Psychology, University of San Francisco, San Francisco, CA, USA
| | - Chengshi Shiu
- Department of Social Work, National Taiwan University, Taipei, Taiwan; School of Nursing, University of California Los Angeles, Los Angeles, CA, USA
| | - Lin Zhang
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Kerong Wang
- Shanghai Public Health Clinical Center, Fudan University, Shanghai 201508, China
| | - Hongzhou Lu
- Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
| | - Hongxin Zhao
- The Third People's Hospital of Shenzhen, Shenzhen 518114, China
| | - Wei-Ti Chen
- School of Nursing, University of California Los Angeles, Los Angeles, CA, USA.
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Smith MK, Luo D, Meng S, Fei Y, Zhang W, Tucker J, Wei C, Tang W, Yang L, Joyner BL, Huang S, Wang C, Yang B, Sylvia SY. An Incognito Standardized Patient Approach for Measuring and Reducing Intersectional Healthcare Stigma. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.21.23294305. [PMID: 37662413 PMCID: PMC10473797 DOI: 10.1101/2023.08.21.23294305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background Consistent evidence highlights the role of stigma in impairing healthcare access in people living with HIV (PLWH), men who have sex with men (MSM), and people with both identities. We developed an incognito standardized patient (SP) approach to obtain observations of providers to inform a tailored, relevant, and culturally appropriate stigma reduction training. Our pilot cluster randomized control trial assessed the feasibility, acceptability, and preliminary effects of an intervention to reduce HIV stigma, anti-gay stigma, and intersectional stigma. Methods Design of the intervention was informed by the results of a baseline round of incognito visits in which SPs presented standardized cases to consenting doctors. The HIV status and sexual orientation of each case was randomly varied, and stigma was quantified as differences in care across scenarios. Care quality was measured in terms of diagnostic testing, diagnostic effort, and patient-centered care. Impact of the training, which consisted of didactic, experiential, and discussion-based modules, was assessed by analyzing results of a follow-up round of SP visits using linear fixed effects regression models. Results Feasibility and acceptability among the 55 provider participants was high. We had a 87.3% recruitment rate and 74.5% completion rate of planned visits (N=238) with no adverse events. Every participant found the training content "highly useful" or "useful." Preliminary effects suggest that, relative to the referent case (HIV negative straight man), the intervention positively impacted testing for HIV negative MSM (0.05 percentage points [PP], 95% CI,-0.24, 0.33) and diagnostic effort in HIV positive MSM (0.23 standard deviation [SD] improvement, 95% CI, -0.92, 1.37). Patient-centered care only improved for HIV positive straight cases post-training relative to the referent group (SD, 0.57; 95% CI, -0.39, 1.53). All estimates lacked statistical precision, an expected outcome of a pilot RCT. Conclusions Our pilot RCT demonstrated high feasibility, acceptability, and several areas of impact for an intervention to reduce enacted healthcare stigma in a low-/middle-income country setting. The relatively lower impact of our intervention on care outcomes for PLWH suggests that future trainings should include more clinical content to boost provider confidence in the safe and respectful management of patients with HIV.
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Religiosity and Engagement in HIV Care Among African American People Living with HIV. J Racial Ethn Health Disparities 2023; 10:560-572. [PMID: 35079959 DOI: 10.1007/s40615-022-01246-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 01/12/2022] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
Abstract
HIV continues to disproportionately impact Black/African Americans. New and innovative strategies are needed to increase and enhance engagement in HIV care. The Black/African American church is a powerful institution with the potential to enhance HIV care among congregants. This study examines perceptions on incorporating religiosity into engagement in HIV care for African Americans living with HIV among Black/African Americans persons living with HIV, church leaders and members, and HIV health and service providers. Findings indicated Black/African Americans living with HIV would be willing to engage in religiously tailored, joint church-health initiatives to increase engagement in care. Church leaders and members and HIV health and service providers also reported a willingness to provide religiously tailored services, and that providing these services would be both acceptable and feasible for implementation. These findings should be considered in future research designed to enhance engagement in HIV care for Black/African Americans living with HIV.
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Lazarus JV, Wohl DA, Cascio M, Guaraldi G, Rockstroh J, Hodson M, Richman B, Brown G, Anderson J, Fuster-RuizdeApodaca MJ. Long-term success for people living with HIV: A framework to guide practice. HIV Med 2023; 24 Suppl 2:8-19. [PMID: 36920412 DOI: 10.1111/hiv.13460] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/16/2023] [Indexed: 03/16/2023]
Abstract
OBJECTIVES In recent decades, the needs of people living with HIV have evolved as life expectancy has greatly improved. Now, a new definition of long-term success (LTS) is necessary to help address the multifaceted needs of all people living with HIV. METHODS We conducted a two-phase research programme to delineate the range of experiences of people living with HIV. The insights garnered from these research phases were explored in a series of expert-led workshops, which led to the development and refinement of the LTS framework. RESULTS The insights generated from the research phases identified a series of themes that form a part of LTS. These themes were subsequently incorporated into the LTS framework, which includes five outcome pillars: sustained undetectable viral load, minimal impact of treatment and clinical monitoring, optimized health-related quality of life, lifelong integration of healthcare, and freedom from stigma and discrimination. A series of supporting statements were also developed by the expert panel to help in the achievement of each of the LTS pillars. CONCLUSIONS The LTS framework offers a comprehensive and person-centric approach that, if achieved, could help improve the long-term well-being of people living with HIV and support the LTS vision of 'every person living with HIV being able to live their best life'.
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Affiliation(s)
- Jeffrey V Lazarus
- Barcelona Institute of Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain.,City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
| | - David A Wohl
- Division of Infectious Diseases, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mario Cascio
- European AIDS Treatment Group (EATG), Palermo, Italy
| | | | - Jürgen Rockstroh
- Department of Medicine I, University Hospital Bonn, Bonn, Germany
| | | | | | - Gina Brown
- Southern AIDS Coalition, Chalmette, Louisiana, USA
| | - Jane Anderson
- Centre for the Study of Sexual Health and HIV, Homerton Healthcare NHS Foundation Trust, London, UK
| | - Maria J Fuster-RuizdeApodaca
- SEISIDA, Spanish AIDS Interdisciplinary Society, Madrid, Spain.,Faculty of Psychology, Universidad Nacional de Educación a Distancia (UNED), Madrid, Spain
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10
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Beichler H, Grabovac I, Dorner TE. Integrated Care as a Model for Interprofessional Disease Management and the Benefits for People Living with HIV/AIDS. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3374. [PMID: 36834069 PMCID: PMC9965658 DOI: 10.3390/ijerph20043374] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/10/2023] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION Today, antiretroviral therapy (ART) is effectively used as a lifelong therapy to treat people living with HIV (PLWH) to suppress viral replication. Moreover, PLWH need an adequate care strategy in an interprofessional, networked setting of health care professionals from different disciplines. HIV/AIDS poses challenges to both patients and health care professionals within the framework of care due to frequent visits to physicians, avoidable hospitalizations, comorbidities, complications, and the resulting polypharmacy. The concepts of integrated care (IC) represent sustainable approaches to solving the complex care situation of PLWH. AIMS This study aimed to describe the national and international models of integrated care and their benefits regarding PLWH as complex, chronically ill patients in the health care system. METHODS We conducted a narrative review of the current national and international innovative models and approaches to integrated care for people with HIV/AIDS. The literature search covered the period between March and November 2022 and was conducted in the databases Cinahl, Cochrane, and Pubmed. Quantitative and qualitative studies, meta-analyses, and reviews were included. RESULTS The main findings are the benefits of integrated care (IC) as an interconnected, guideline- and pathway-based multiprofessional, multidisciplinary, patient-centered treatment for PLWH with complex chronic HIV/AIDS. This includes the evidence-based continuity of care with decreased hospitalization, reductions in costly and burdensome duplicate testing, and the saving of overall health care costs. Furthermore, it includes motivation for adherence, the prevention of HIV transmission through unrestricted access to ART, the reduction and timely treatment of comorbidities, the reduction of multimorbidity and polypharmacy, palliative care, and the treatment of chronic pain. IC is initiated, implemented, and financed by health policy in the form of integrated health care, managed care, case and care management, primary care, and general practitioner-centered concepts for the care of PLWH. Integrated care was originally founded in the United States of America. The complexity of HIV/AIDS intensifies as the disease progresses. CONCLUSIONS Integrated care focuses on the holistic view of PLWH, considering medical, nursing, psychosocial, and psychiatric needs, as well as the various interactions among them. A comprehensive expansion of integrated care in primary health care settings will not only relieve the burden on hospitals but also significantly improve the patient situation and the outcome of treatment.
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Affiliation(s)
- Helmut Beichler
- Nursing School, Vienna General Hospital, Medical University of Vienna, 1090 Vienna, Austria
| | - Igor Grabovac
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas E. Dorner
- Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, 1090 Vienna, Austria
- Academy for Ageing Research, Haus der Barmherzigkeit, 1090 Vienna, Austria
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11
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Sprague C. What Matters Most? The Power of Kafka's Metamorphosis to Advance Understandings of HIV Stigma and Inform Empathy in Medical Health Education. THE JOURNAL OF MEDICAL HUMANITIES 2022; 43:561-584. [PMID: 35188615 PMCID: PMC8858723 DOI: 10.1007/s10912-022-09729-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
HIV stigma, a social-medical problem, continues to confound researchers and health professionals, while undermining outcomes. Empathy may reduce stigma; its absence may predict stigma. This research investigates: How does Kafka's Metamorphosis advance understandings of HIV stigma in medical health education? Metamorphosis amplifies the sociological-relational mechanisms fostering HIV stigma. It offers a multi-disciplinary, responsive space for ethical, humanistic and clinical inquiry to meet: enabling students to consider how social structures shape health inequities, moral, social experience, and their professional identity within. Metamorphosis may ultimately promote medical health humanities' social mission-allowing literature to unfold such revelations towards greater equity in health.
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Gleicher ST, Chalmiers MA, Aiyanyor B, Jain R, Kotha N, Scott K, Song RS, Tram J, Vuong CL, Kesselheim J. Confronting implicit bias toward patients: a scoping review of post-graduate physician curricula. BMC MEDICAL EDUCATION 2022; 22:696. [PMID: 36175856 PMCID: PMC9520104 DOI: 10.1186/s12909-022-03720-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/03/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Physicians' behavior may unknowingly be impacted by prejudice and thereby contribute to healthcare inequities. Despite increasingly robust data demonstrating physician implicit bias (The Office of Minority Health. Minority Population Profiles, 2021; COVID-19 Shines Light on Health Disparities, National Conference of State Legislatures 2021), the evidence behind how to change this with training programs remains unclear. This scoping review therefore reports on the implementation, outcomes, and characteristics of post-graduate physician implicit bias curricula. METHODS The authors conducted a literature review using scoping review methodology. They searched 7 databases in February and November 2020 for English-language academic and gray literature on implicit bias curricula for physicians at all levels of post-graduate training. Ten reviewers screened studies for eligibility independently, then extracted data from these studies and compiled it into a chart and analytical summary. RESULTS Of the 4,599 articles screened, this review identified 90 articles on implicit bias interventions for post-graduate physicians. Inductive data analysis revealed a spectrum of educational approaches, which were categorized int o 4 educational models called Competence, Skills-Based, Social Contact, and Critical Models. The most commonly reported strength was the interactive nature of the curricula (26%), and the most frequently identified challenges were related to time and resources available (53%). Half of the interventions discussed facilitator preparation, and the majority (62%) evaluated outcomes using pre and post self-assessments. CONCLUSIONS This review provides a comprehensive synthesis of the literature on physician implicit bias curricula. It is our goal that this supports medical educators in applying and improving aspects of these interventions in their own programs.
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Affiliation(s)
- S T Gleicher
- Neurology, University of Washington, Seattle, USA.
| | - M A Chalmiers
- School of Medicine, University of California San Diego, San Diego, USA
| | - B Aiyanyor
- Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, USA
| | - R Jain
- Pediatric Hematology/Oncology, University of California San Francisco, San Francisco, USA
| | - N Kotha
- School of Medicine, University of California San Diego, San Diego, USA
| | - K Scott
- Neonatal Intensive Care, Children's Hospital of Philadelphia, Philadelphia, USA
| | | | - J Tram
- School of Medicine, University of California San Diego, San Diego, USA
| | - C L Vuong
- Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, USA
| | - J Kesselheim
- DFCI/BCH Cancer and Blood Disorders Center, Harvard Medical School, Boston, USA
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Budhwani H, Paulino-Ramírez R, Waters J, Bond CL, Ruiz I, Long DM, Varas-Díaz N, Naar S, Nyblade L, Turan JM. Adapting and pilot testing an HIV and intersectional stigma reducing intervention for Dominican Republic healthcare contexts: Protocol for translational research. Contemp Clin Trials Commun 2022; 29:100980. [PMID: 36060154 PMCID: PMC9434029 DOI: 10.1016/j.conctc.2022.100980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/22/2022] [Accepted: 08/09/2022] [Indexed: 02/04/2023] Open
Abstract
Background This protocol details the adaptation and pilot testing of the Finding Respect and Ending Stigma around HIV (FRESH) intervention in Dominican Republic. FRESH is a healthcare setting stigma-reduction intervention designed to reduce stigmas affecting people living with HIV (PLHIV), focusing on HIV and intersectional stigmas experienced by sexual and gender minority (SGM) people living with HIV. After the successful adaptation of the FRESH intervention, it will be pilot-tested through the conduct of a pilot stepped wedge cluster randomized controlled trial. Methods Three aims are included in this study; Aim 1 includes exploratory qualitative assessment, specifically the conduct four focus groups with men who have sex with men (MSM) living with HIV (n = 24-32) and in-depth interviews with transgender women living with HIV to explore their experiences with stigma in clinics (n = 9-12). In-depth interviews will also be held with HIV healthcare workers to elucidate their perceptions and behaviors towards their SGM clients (n = 9-12). In Aim 2, informed by Aim 1 data, we will use the sequential phases of the ADAPT-ITT framework to iteratively adapt the FRESH intervention for the Dominican Republic. In Aim 3, the adapted intervention will be pilot-tested via a cluster stepped wedge randomized controlled trial to assess feasibility and acceptability of the intervention and study protocols. Conclusions If this pilot trial is successful, next steps will include testing the adapted intervention across Dominican Republic or in similar Spanish-speaking Caribbean nations in a larger trial to assess effectiveness in reducing stigma in clinical settings towards PLHIV.
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Affiliation(s)
- Henna Budhwani
- Florida State University, College of Nursing, Center of Population Sciences for Health Equity, Tallahassee, FL, United States
- Corresponding author. Florida State University, College of Nursing, Center of Population Sciences for Health Equity, 2010 Levy Avenue, Building B, Suite 3600, Tallahassee, FL, 32306, United States.
| | | | - John Waters
- Caribbean Vulnerable Communities Coalition (CVC), Kingston, Jamaica
| | - Christyenne L. Bond
- Florida State University, College of Nursing, Center of Population Sciences for Health Equity, Tallahassee, FL, United States
| | - Ingrid Ruiz
- Universidad Iberoamericana (UNIBE), Santo Domingo, Dominican Republic
| | - Dustin M. Long
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, United States
| | - Nelson Varas-Díaz
- Florida International University, Department of Global and Sociocultural Studies, Miami, FL, United States
| | - Sylvie Naar
- Florida State University, Department of Behavioral Sciences and Social Medicine, Tallahassee, FL, United States
| | - Laura Nyblade
- Research Triangle Institute (RTI) International, Research Triangle Park, NC, United States
| | - Janet M. Turan
- University of Alabama at Birmingham, School of Public Health, Birmingham, AL, United States
- Koç University, School of Medicine, Istanbul, Turkey
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Pollack TM, Duong HT, Nhat Vinh DT, Phuong DT, Thuy DH, Nhung VTT, Uyen NK, Linh VT, Van Truong N, Le Ai KA, Ninh NT, Nguyen A, Canh HD, Cosimi LA. A pretest-posttest design to assess the effectiveness of an intervention to reduce HIV-related stigma and discrimination in healthcare settings in Vietnam. J Int AIDS Soc 2022; 25 Suppl 1:e25932. [PMID: 35818864 PMCID: PMC9274370 DOI: 10.1002/jia2.25932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 05/03/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Stigma and discrimination are important barriers to HIV epidemic control. We implemented a multi‐pronged facility‐level intervention to reduce stigma and discrimination at health facilities across three high‐burden provinces. Key components of the intervention included measurement of stigma, data review and use, participatory training of healthcare workers (HCWs), and engagement of people living with HIV and key populations in all stigma reduction activities. Methods From July 2018 to July 2019, we assessed HIV‐related stigma and discrimination among patients and HCWs at 10 facilities at baseline and 9 months following an intervention. A repeated measures design was used to assess the change in stigma and discrimination among HCWs and a repeated cross‐sectional design assessed the change in stigma and discrimination experienced by PLHIV. HCWs at target facilities were invited at random and PLHIV were recruited when presenting for care during the two assessment periods. McNemar's test was used to compare paired proportions among HCWs, and chi‐square test was used to compare proportions among PLHIV. Mixed models were used to compare outcomes before and after the intervention. Results Semi‐structured interviews were conducted with 649 and 652 PLHIV prior to and following the intervention, respectively. At baseline, over the previous 12 months, 21% reported experiencing discrimination, 16% reported self‐stigma, 14% reported HIV disclosure without consent and 7% had received discriminatory reproductive health advice. Nine months after the intervention, there was a decrease in reported stigma and discrimination across all domains to 15%, 11%, 7% and 3.5%, respectively (all p‐values <0.05). Among HCWs, 672 completed the pre‐ and post‐intervention assessment. At baseline, 81% reported fear of HIV infection, 69% reported using unnecessary precautions when caring for PLHIV, 44% reported having observed other staff discriminate against PLHIV, 54% reported negative attitudes towards PLHIV and 41% felt uncomfortable working with colleagues living with HIV. The proportions decreased after the intervention to 52%, 34%, 32%, 35% and 24%, respectively (all p‐values <0.05). Conclusions A multi‐pronged facility‐level intervention was successful at reducing healthcare‐associated HIV‐related stigma in Vietnam. The findings support the scale‐up of this intervention in Vietnam and highlight key components potentially applicable in other settings.
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Affiliation(s)
- Todd M Pollack
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Baylor College of Medicine, Houston, Texas, USA
| | - Hao Thi Duong
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam.,Baylor College of Medicine, Houston, Texas, USA
| | | | - Do Thi Phuong
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam
| | - Do Huu Thuy
- Vietnam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | | | | | - Vuong The Linh
- Binh Duong Center for Disease Control, Binh Duong, Vietnam
| | | | - Kim Anh Le Ai
- Thai Nguyen Center for Disease Control, Thai Nguyen, Vietnam
| | | | - Asia Nguyen
- Division of Global HIV and TB, Center for Global Health, United States Centers for Disease Control and Prevention Vietnam, Hanoi, Vietnam
| | - Hoang Dinh Canh
- Vietnam Authority of HIV/AIDS Control, Ministry of Health, Hanoi, Vietnam
| | - Lisa A Cosimi
- Partnership for Health Advancement in Vietnam, Hanoi, Vietnam.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Li X, Qiao S, Yang X, Harrison SE, Tam CC, Shen Z, Zhou Y. A Resilience-Based Intervention to Mitigate the Effect of HIV-Related Stigma: Protocol for a Stepped Wedge Cluster Randomized Trial. Front Public Health 2022; 10:857635. [PMID: 35425746 PMCID: PMC9001957 DOI: 10.3389/fpubh.2022.857635] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/10/2022] [Indexed: 11/29/2022] Open
Abstract
Background Despite decades of global efforts to tackle HIV-related stigma, previous interventions designed to reduce stigma have had limited effects that were typically in the small- to-moderate range. The knowledge gaps and challenges for combating HIV-related stigma are rooted both in the complexity of the stigma and in the limitations of current conceptualizations of stigma reduction efforts. Recent research has shown the promise of resilience-based approaches that focus on the development of strengths, competencies, resources, and capacities of people living with HIV (PLWH) and their key supporting systems (e.g., family members and healthcare providers) to prevent, reduce, and mitigate the negative effects of stigma. However, the resilience-based approach, while hypothesized, has rarely been empirically tested in large intervention trials, especially in resource-limited settings. Methods In this study, we propose to develop, implement, and evaluate a theory-guided, multilevel, multimodal resilience-based intervention via a stepped wedge cluster randomized trial among 800 PLWH and their biological or surrogate family members, as well as 320 healthcare providers in Guangxi, China with a longitudinal follow-up period of 36 months at 6-month intervals. The primary outcome will be viral suppression and the intermediate outcomes will include perceived stress and medication adherence of PLWH as well as resilience measures at the level of the individual, the family, and the healthcare system. Discussion The proposed study will be one of the first large scale efforts to examine whether resilience among PLWH can be fostered and sustained through a multilevel and multi-component HIV-related stigma intervention and whether a resilience-based intervention can improve clinical outcomes and quality of HIV care among PLWH in a low-resource setting. If efficacious, the intervention components could be tailored to other groups of PLWH and adapted for other low- and middle-income countries. Trial Registration This trial is registered at ClinicalTrials.gov, registration number NCT05174936, registered 13 December 2021. https://register.clinicaltrials.gov/prs/app/action/LoginUser?ts=3&cx=-jg9qo2.
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Affiliation(s)
- Xiaoming Li
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.,Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Shan Qiao
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.,Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Xueying Yang
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.,Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Sayward E Harrison
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.,Department of Psychology, College of Arts and Sciences, University of South Carolina, Columbia, SC, United States
| | - Cheuk Chi Tam
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States.,Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, United States
| | - Zhiyong Shen
- Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Guangxi, China
| | - Yuejiao Zhou
- Guangxi Zhuang Autonomous Region Center for Disease Prevention and Control, Guangxi, China
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16
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Price DM, Unger Z, Wu Y, Meyers K, Golub SA. Clinic-Level Strategies for Mitigating Structural and Interpersonal HIV Pre-Exposure Prophylaxis Stigma. AIDS Patient Care STDS 2022; 36:115-122. [PMID: 35289691 PMCID: PMC8971970 DOI: 10.1089/apc.2021.0176] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Uptake of and persistence on pre-exposure prophylaxis (PrEP) in the United States have been limited. The potential of new PrEP modalities to increase access will be hindered if underlying structural and interpersonal barriers-including, insurance coverage, initiation and maintenance clinical protocols, provider bias, stigma, and lack of trust in health care-are not adequately addressed. We conducted in-person and telephone-based recorded interviews with 32 US-based clinical and nonclinical PrEP providers spanning the PrEP implementation continuum (clinicians, counselors, and support staff). Providers were recruited at biomedical HIV prevention conferences and networks to explore barriers to and strategies for PrEP implementation. Providers provided care to clients spanning adolescents to adulthood and a variety of genders across all geographic regions of the United States. To directly mitigate stigma, providers called for clinic-level interventions to normalize and universalize PrEP education and services, counseling and other services that center patients' lived experiences and circumstance, staffing and community engagement models that value patients, and implementation of specific programs and processes that facilitate access to services. To address disparities in access, PrEP implementation should acknowledge the interconnectedness of stigma and structural barriers to care.
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Affiliation(s)
- Devon M. Price
- Department of Psychology, Hunter College, City University of New York, New York, New York, USA.,Address correspondence to: Devon M. Price, PhD, Department of Psychology, Hunter College, City University of New York, 695 Park Avenue, New York, NY 10065-5024, USA
| | - Zoe Unger
- Department of Psychology, Hunter College, City University of New York, New York, New York, USA
| | - Yumeng Wu
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Kathrine Meyers
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA.,Division of Infectious Diseases, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Sarit A. Golub
- Department of Psychology, Hunter College, City University of New York, New York, New York, USA.,Department of Psychology, The Graduate Center of the City University of New York, New York, New York, USA
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Mohammadifirouzeh M, Oh KM, Tanner S. HIV stigma reduction interventions among health care providers and students in different countries: a systematic review. Curr HIV Res 2021; 20:20-31. [PMID: 34872477 DOI: 10.2174/1570162x19666211206094709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/21/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Health care providers' stigmatizing attitudes are obstacles to patients' well-being and quality of life. Dealing with HIV-related stigma and understanding the impact of feasible interventions on reducing stigmatizing attitudes among health care providers are considered important strategies to improve the quality of HIV care, patient-provider relationships, and provide supportive and safe care services. OBJECTIVES The aim of this study was to systematically review interventions to reduce HIV-related stigma among health care providers. METHODS This systematic review was performed using Medline, CINAHL, ERIC, and APA PsycInfo, Health Source: Nursing/Academic Edition to search for quasi-experimental studies and randomized controlled trials (RCTs) designed to reduce HIV stigma among health care providers. The quality of eligible research studies was independently appraised by two reviewers. RESULTS A total of 774 studies were screened, 100 articles were assessed for the eligibility, and 10 studies met the inclusion criteria. All interventions effectively reduced HIV-related stigma. Elements of successful interventions including knowledge modules, peer education, patients' testimonials, Photovoice-informed stigma reduction training, stigma-free space intervention, and popular opinion leaders. Interventions were assessed and compared in terms of contents, delivery modes, HIV stigma measurements, follow-up, and limitations. CONCLUSIONS This systematic review supports the effectiveness of in-person educational interventions at reducing HIV-related stigma among health care providers across countries. Comparisons of delivery modes of interventions indicated that educational interventions delivered by patients' testimonials and peer education strategies are more promising than lecture-based teaching methods. Further studies are needed to assess long-term effects of interventions on clinical behaviors and practices.
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Affiliation(s)
- Mona Mohammadifirouzeh
- George Mason University, School of Nursing 4400 University Dr, Fairfax,VA 22030. United States
| | - Kyeung Mi Oh
- George Mason University, School of Nursing 4400 University Dr, Fairfax,VA 22030. United States
| | - Susan Tanner
- George Mason University, School of Nursing 4400 University Dr, Fairfax,VA 22030. United States
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Crane ME, Atkins MS, Becker SJ, Purtle J, Olino TM, Kendall PC. The effect of caregiver key opinion leaders on increasing caregiver demand for evidence-based practices to treat youth anxiety: protocol for a randomized control trial. Implement Sci Commun 2021; 2:107. [PMID: 34556182 PMCID: PMC8460198 DOI: 10.1186/s43058-021-00213-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 09/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background Research has identified cognitive behavioral therapy with exposures (CBT) as an effective treatment for youth anxiety. Despite implementation efforts, few anxious youth receive CBT. Direct-to-consumer marketing offers a different approach to address the unmet need for youth receiving effective treatments. Involving a local caregiver key opinion leader in direct-to-consumer initiatives may be an effective strategy to increase caregiver demand for CBT. Research indicates that key opinion leaders improve health promotion campaigns, but key opinion leaders have not been studied in the context of increasing caregiver demand for evidence-based treatments. Method Project CHAT (Caregivers Hearing about Anxiety Treatments) will test the role of key opinion leader participation in conducting outreach presentations to increase caregiver desire to seek CBT for their youth’s anxiety. Caregiver attendees (N = 180) will be cluster randomized by school to receive one of two different approaches for presentations on CBT for youth anxiety. Both approaches will involve community outreach presentations providing information on recognizing youth anxiety, strategies caregivers can use to decrease youth anxiety, and how to seek CBT for youth anxiety. The researcher-only condition will be co-facilitated by two researchers. In the key opinion leader condition, a caregiver key opinion leader from each local community will be involved in tailoring the content of the presentation to the context of the community, co-facilitating the presentation with a researcher, and endorsing strategies in the presentation that they have found to be helpful. In line with the theory of planned behavior, caregiver attendees will complete measures assessing their knowledge of, attitudes towards, perceived subjective norms about, and intention to seek CBT pre- and post-presentation; they will indicate whether they sought CBT for their youth at 3-month follow-up. Results will be analyzed using a mixed method approach to assess the effectiveness of a key opinion leader to increase caregiver demand for CBT. Discussion This study will be the first to examine the potential of key opinion leaders to increase caregiver demand for CBT. If proven effective, the use of key opinion leaders could serve as a scalable dissemination strategy to increase the reach of evidence-based treatments. Trial registration This trial was registered on clinicaltrials.gov (NCT04929262) on June 18, 2021. At the time of trial registration, pre/post-presentation data had been collected from 17 participants; thus, it was retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s43058-021-00213-x.
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Affiliation(s)
- Margaret E Crane
- Department of Psychology, Temple University, Weiss Hall, 1701 North 13th Street, Philadelphia, PA, 19122, USA.
| | - Marc S Atkins
- Institute for Juvenile Research, Department of Psychiatry, University of Illinois, Chicago, 1747 West Roosevelt Road, Suite 155, Chicago, IL, 60608, USA
| | - Sara J Becker
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Box G-S121-5, Providence, RI, 02912, USA
| | - Jonathan Purtle
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Nesbitt Hall, Room 351, 3215 Market St, Philadelphia, PA, 19104, USA
| | - Thomas M Olino
- Department of Psychology, Temple University, Weiss Hall, 1701 North 13th Street, Philadelphia, PA, 19122, USA
| | - Philip C Kendall
- Department of Psychology, Temple University, Weiss Hall, 1701 North 13th Street, Philadelphia, PA, 19122, USA
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Ceylan E, Koç A. Effect of peer education model on nursing students' knowledge and attitudes towards HIV/AIDS. NURSE EDUCATION TODAY 2021; 99:104808. [PMID: 33610052 DOI: 10.1016/j.nedt.2021.104808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/22/2020] [Accepted: 02/02/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES This research is an intervention study designed as a single group pre-test post-test model without control group in order to examine the effect of education provided to nursing students based on peer education model on HIV/AIDS knowledge level and attitude. DESIGN, METHODS, SETTINGS AND PARTICIPANTS The research was carried out at Nursing Department of Ankara Yıldırım Beyazıt University. Sample of the study consisted of second year nursing students who agreed to participate in the study and enrolled Internal Medicine Nursing course for the first time (n = 88). In the first stage of the study, nine peer mentors were selected and a total of 12 h of training were given to them by the researchers. In the second stage, peer mentors provided a total of 12 h of training to nine peer students groups. All groups were created by simple randomization on the "research randomizer" website. Demographics questionnaire, AIDS knowledge scale and AIDS attitude scale were used to collect the data. Data was analyzed by using descriptive statistics, Pearson Chi-square test, paired sample t-Test, Wilcoxon test and Spearman correlation test. RESULTS It was determined that peer education provided a statistically significant increase in AIDS knowledge scale score in peer students (pretest x¯=10.32 ± 3.59, posttest x¯=19.69 ± 1.51) (p < 0.001). In addition, peer education was found to provide a statistically significant increase in AIDS attitude scale score in peer students (pretest x¯=56.64 ± 8.36, posttest x¯=72.95 ± 7.02) (p < 0.001). CONCLUSION It has been determined that peer education method is an effective method in increasing HIV/AIDS knowledge and attitude towards people living with HIV/AIDS in nursing students. Therefore, it is recommended to include peer education model in nursing educations regarding HIV/AIDS.
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Affiliation(s)
- Erdal Ceylan
- Ankara Yıldırım Beyazıt University, Faculty of Health Sciences, Nursing Department, Ankara, Turkey.
| | - Ayşegül Koç
- Ankara Yıldırım Beyazıt University, Faculty of Health Sciences, Nursing Department, Ankara, Turkey
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Abstract
Purpose of Review HIV and ageism continue to be key public health challenges in the USA and globally. Older people living with HIV may experience intersectional stigma resulting from HIV and ageism. The current review summarizes the scientific literature and focuses on social isolation and lack of social support as key factors in experiencing HIV-related and aging-related stigma. Recent Findings Social isolation and social support are key social determinants of health, which may have a bidirectional relationship with HIV-related stigma and ageism. Stigmatization may also result in health care providers not paying enough attention to the mental health and sexual health needs of older adults. Summary Current research suggests that the intersection of HIV-related stigma and ageism is a complex issue. Future research should focus on the design and feasibility of implementing stigma reduction interventions addressing HIV-related stigma and ageism.
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Affiliation(s)
- Monique J. Brown
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208 USA
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Office for the Study on Aging, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
| | - Oluwafemi Adeagbo
- South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC USA
- Department of Sociology, Faculty of Humanities, University of Johannesburg, Johannesburg, South Africa
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21
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Nyblade L, Srinivasan K, Raj T, Oga EA, Heylen E, Mazur A, Devadass D, Steward WT, Pereira M, Ekstrand ML. HIV Transmission Worry Predicts Discrimination Intentions Among Nursing Students and Ward Staff in India. AIDS Behav 2021; 25:389-396. [PMID: 32804318 PMCID: PMC7855682 DOI: 10.1007/s10461-020-03001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Health facility stigma impedes HIV care and treatment. Worry of contracting HIV while caring for people living with HIV is a key driver of health facility stigma, however evidence for this relationship is largely cross-sectional. This study evaluates this relationship longitudinally amongst nursing students and ward staff in India. Worry of contracting HIV and other known predictors of intent to discriminate were collected at baseline and 6 months in 916 nursing students and 747 ward staff. Using fixed effects regression models, we assessed the effect of key predictors on intent to discriminate over a 6-month period. Worry of contracting HIV predicted intent to discriminate for nursing students and ward staff in care situations with low and high-risk for bodily fluid exposure, confirming prior cross-sectional study results and underscoring the importance of addressing worry of contracting HIV as part of health facility HIV stigma-reduction interventions.
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Affiliation(s)
- Laura Nyblade
- Global Health Division, International Development Group, RTI International, 13th St., NW, Suite 750, Washington, DC, 20005, USA.
| | - Krishnamachari Srinivasan
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Tony Raj
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Emmanuel A Oga
- Center for Applied Public Health Research, RTI International, Rockville, MD, USA
| | - Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Amanda Mazur
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Dhinagaran Devadass
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Wayne T Steward
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
| | - Matilda Pereira
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
| | - Maria L Ekstrand
- St. Johns Research Institute, St. John's National Academy of Health Sciences, Bangalore, Karnataka, India
- Center for AIDS Prevention Studies, Department of Medicine, University of California, San Francisco, CA, USA
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Sommerland N, Masquillier C, Rau A, Engelbrecht M, Kigozi G, Pliakas T, Janse van Rensburg A, Wouters E. Reducing HIV- and TB-Stigma among healthcare co-workers in South Africa: Results of a cluster randomised trial. Soc Sci Med 2020; 266:113450. [PMID: 33126096 DOI: 10.1016/j.socscimed.2020.113450] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/11/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
RATIONALE The HIV and TB co-epidemic has a severe impact on the South African healthcare workforce and health system. HIV- and TB- stigma directed from healthcare workers (HCWs) towards colleagues not only has a negative impact on the mental health and well-being of the HCWs, but has been identified as a barrier to their own health-seeking behaviour. It also increases the strain on the health system due to absenteeism. OBJECTIVE This cluster-randomised trial tested an intervention to reduce HIV- and TB-stigma among HCWs. The intervention, based on the theory of Diffusion of Innovations consisted of training healthcare workers as change agents in a Social and Behavioural Change Communication workshop to help them change stigmatising attitudes in the workplace. This was supported by a social marketing campaign. METHODS Eight hospitals in the Free State province were randomised into intervention and control group in a stratified study design. 652 respondents randomly drawn from the hospitals were surveyed on aspects of HIV and TB stigma once in 2016 and again in 2018. Since the study only used four hospitals per intervention arm, cluster-based summaries were compared when analysing the intervention effect, using the nonparametric Mann-Whitney test. To explore how the intervention worked, 24 qualitative focus groups were conducted following the intervention. RESULTS The quantitative test did not show a significant intervention effect on stigma between intervention and control groups. Qualitative evidence reported new awareness and changed behaviour related to HIV- and TB-stigma among individual HCWs, but a combination of factors including strong social hierarchies in the workplace and the down-scaling of the original version of the intervention seemed to reduce the impact. Conclusion The findings did not indicate a significant intervention effect, but show the potential of using HCWs as change agents to reduce HIV and TB stigma in their local communities.
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Affiliation(s)
- Nina Sommerland
- Centre for Population, Family and Health, Department of Sociology, University of Antwerp, Antwerp, Belgium.
| | - Caroline Masquillier
- Centre for Population, Family and Health, Department of Sociology, University of Antwerp, Antwerp, Belgium
| | - Asta Rau
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
| | - Michelle Engelbrecht
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
| | - Gladys Kigozi
- Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa
| | - Triantafyllos Pliakas
- Centre for Evaluation, Department Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Edwin Wouters
- Centre for Population, Family and Health, Department of Sociology, University of Antwerp, Antwerp, Belgium
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Integration and scale-up of efforts to measure and reduce HIV-related stigma: the experience of Thailand. AIDS 2020; 34 Suppl 1:S103-S114. [PMID: 32881799 DOI: 10.1097/qad.0000000000002586] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE(S) To share Thailand's journey to develop and implement a national response to measure and tackle HIV-related stigma and discrimination and key implementation lessons learned. DESIGN A national response to stigma and discrimination including policy, measurement, and interventions. Intervention activities began in health facilities because of their key role in achieving health outcomes. METHODS Three building blocks were implemented: policy and its translation into a roadmap for action; measurement development and routinization to inform intervention design and track progress; and intervention development and implementation. RESULTS Thailand has successfully integrated a response to stigma and discrimination into its national HIV response. Stigma and discrimination-reduction was included as a key strategic goal for the first time in the 2014-2016 National AIDS Strategic Plan. A costed national stigma and discrimination-reduction roadmap incorporated into the operational plan provided clear strategic direction on how to move forward. The development of HIV-related stigma and discrimination measures and their incorporation into the national HIV monitoring and evaluation framework has led to routine data collection to monitor stigma and discrimination in health facilities, key populations, and the general population. Development and successful piloting of a health facility stigma-reduction package - the 3 × 4 approach - has led to national scale-up of the approach through a modified approach. Thailand continues to evolve and innovate the program, including developing new activities to tackle stigma and discrimination beyond the health system. CONCLUSION Thailand's experience demonstrates the key elements needed to make addressing stigma and discrimination a priority in the national HIV response.
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A total facility approach to reducing HIV stigma in health facilities: implementation process and lessons learned. AIDS 2020; 34 Suppl 1:S93-S102. [PMID: 32881798 DOI: 10.1097/qad.0000000000002585] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To describe development and implementation of a three-stage 'total facility' approach to reducing health facility HIV stigma in Ghana and Tanzania, to facilitate replication. DESIGN HIV stigma in healthcare settings hinders the HIV response and can occur during any interaction between client and staff, between staff, and within institutional processes and structures. Therefore, the design focuses on multiple socioecological levels within a health facility and targets all levels of staff (clinical and nonclinical). METHODS The approach is grounded in social cognitive theory principles and interpersonal or intergroup contact theory that works to combat stigma by creating space for interpersonal interactions, fostering empathy, and building efficacy for stigma reduction through awareness, skills, and knowledge building as well as through joint action planning for changes needed in the facility environment. The approach targets actionable drivers of stigma among health facility staff: fear of HIV transmission, awareness of stigma, attitudes, and health facility environment. RESULTS The results are the three-stage process of formative research, capacity building, and integration into facility structures and processes. Key implementation lessons learned included the importance of formative data to catalyze action and shape intervention activities, using participatory training methodologies, involving facility management throughout, having staff, and clients living with HIV facilitate trainings, involving a substantial proportion of staff, mixing staff cadres and departments in training groups, and integrating stigma-reduction into existing structures and processes. CONCLUSION Addressing stigma in health facilities is critical and this approach offers a feasible, well accepted method of doing so.
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Bogart LM, Matovu JKB, Wagner GJ, Green HD, Storholm ED, Klein DJ, Marsh T, MacCarthy S, Kambugu A. A Pilot Test of Game Changers, a Social Network Intervention to Empower People with HIV to be Prevention Advocates in Uganda. AIDS Behav 2020; 24:2490-2508. [PMID: 32030525 DOI: 10.1007/s10461-020-02806-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We conducted a pilot randomized controlled trial of Game Changers, a 6-session group intervention that empowers people with HIV to be HIV prevention advocates in their social networks. Ninety-nine people with HIV (51 intervention, 48 wait-list control) and 58 of their social network members (alters) completed baseline and 5- and 8-month post-baseline assessments. Results indicated high acceptability, demonstrated by participants' and facilitators' positive attitudes qualitatively and favorable ratings of intervention sessions quantitatively, and high feasibility (76% attended all intervention sessions). Intention-to-treat analyses indicated significantly increased HIV prevention advocacy among HIV-positive participants and alters [b (SE) = 0.4 (0.2), p = .017; b (SE) = 0.4 (0.2), p = .035]; reduced internalized HIV stigma [b (SE) = - 0.3 (0.1), p = .012], increased HIV-serostatus disclosure [b (SE) = 0.1 (0.1), p = .051], and increased social network density among HIV-positive participants [b (SE) = 0.1 (0.03), p = .004]; and marginally reduced condomless sex among alters [OR (95% CI) = 0.3 (0.1-1.2), p = .08]. Positioning people with HIV as central to prevention has the potential to reduce stigma and improve prevention outcomes throughout social networks.
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Smith MK, Xu RH, Hunt SL, Wei C, Tucker JD, Tang W, Luo D, Xue H, Wang C, Yang L, Yang B, Li L, Joyner BL, Sylvia SY. Combating HIV stigma in low- and middle-income healthcare settings: a scoping review. J Int AIDS Soc 2020; 23:e25553. [PMID: 32844580 PMCID: PMC7448195 DOI: 10.1002/jia2.25553] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 05/08/2020] [Accepted: 05/20/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Nearly 40 years into the HIV epidemic, the persistence of HIV stigma is a matter of grave urgency. Discrimination (i.e. enacted stigma) in healthcare settings is particularly problematic as it deprives people of critical healthcare services while also discouraging preventive care seeking by confirming fears of anticipated stigma. We review existing research on the effectiveness of stigma interventions in healthcare settings of low- and middle-income countries (LMIC), where stigma control efforts are often further complicated by heavy HIV burdens, less developed healthcare systems, and the layering of HIV stigma with discrimination towards other marginalized identities. This review describes progress in this field to date and identifies research gaps to guide future directions for research. METHODS We conducted a scoping review of HIV reduction interventions in LMIC healthcare settings using Embase, Ovid MEDLINE, PsycINFO and Scopus (through March 5, 2020). Information regarding study design, stigma measurement techniques, intervention features and study findings were extracted. We also assessed methodological rigor using the Joanna Briggs Institute checklist for systematic reviews. RESULTS AND DISCUSSION Our search identified 8766 studies, of which 19 were included in the final analysis. All but one study reported reductions in stigma following the intervention. The studies demonstrated broad regional distribution across LMIC and many employed designs that made use of a control condition. However, these strengths masked key shortcomings including a dearth of research from the lowest income category of LMIC and a lack of interventions to address institutional or structural determinants of stigma. Lastly, despite the fact that most stigma measures were based on existing instruments, only three studies described steps taken to validate or adapt the stigma measures to local settings. CONCLUSIONS Combating healthcare stigma in LMIC demands interventions that can simultaneously address resource constraints, high HIV burden and more severe stigma. Our findings suggest that this will require more objective, reliable and culturally adaptable stigma measures to facilitate meaningful programme evaluation and comparison across studies. All but one study concluded that their interventions were effective in reducing healthcare stigma. Though encouraging, the fact that most studies measured impact using self-reported measures suggests that social desirability may bias results upwards. Homogeneity of study results also hindered our ability to draw substantive conclusions about potential best practices to guide the design of future stigma reduction programmes.
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Affiliation(s)
- M. Kumi Smith
- Division of Epidemiology & Community HealthUniversity of Minnesota Twin CitiesMinneapolisMNUSA
| | - Richie H. Xu
- Division of Epidemiology & Community HealthUniversity of Minnesota Twin CitiesMinneapolisMNUSA
| | - Shanda L. Hunt
- Health Sciences LibrariesUniversity of Minnesota Twin CitiesMinneapolisMNUSA
| | - Chongyi Wei
- Department of Health Behavior, Society and PolicyRutgers UniversityNew BrunswickNYUSA
| | - Joseph D. Tucker
- Institute for Global Health and Infectious DiseasesSchool of MedicineUniversity of North CarolinaChapel HillNCUSA
- London School of Hygiene and Tropical MedicineLondonUK
| | - Weiming Tang
- Institute for Global Health and Infectious DiseasesSchool of MedicineUniversity of North CarolinaChapel HillNCUSA
| | | | - Hao Xue
- Freeman Spogli Institute for International StudiesStanford UniversityStanfordCAUSA
| | - Cheng Wang
- Dermatology Hospital of Southern Medical UniversityGuangzhouChina
| | - Ligang Yang
- Dermatology Hospital of Southern Medical UniversityGuangzhouChina
| | - Bin Yang
- Dermatology Hospital of Southern Medical UniversityGuangzhouChina
| | - Li Li
- Department of EpidemiologyUniversity of CaliforniaLos AngelesCAUSA
| | - Benny L. Joyner
- Division of Pediatric Critical Care MedicineSchool of MedicineUniversity of North CarolinaChapel HillNCUSA
| | - Sean Y. Sylvia
- Department of Health Policy & ManagementUniversity of North CarolinaChapel HillNCUSA
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Nyblade L, Addo NA, Atuahene K, Alsoufi N, Gyamera E, Jacinthe S, Leonard M, Mingkwan P, Stewart C, Vormawor R, Kraemer JD. Results from a difference-in-differences evaluation of health facility HIV and key population stigma-reduction interventions in Ghana. J Int AIDS Soc 2020; 23:e25483. [PMID: 32329153 PMCID: PMC7180216 DOI: 10.1002/jia2.25483] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/07/2020] [Accepted: 03/04/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Stigma undermines all aspects of a comprehensive HIV response, as reflected in recent global initiatives for stigma-reduction. Yet a commensurate response to systematically tackle stigma within country responses has not yet occurred, which may be due to the lack of sufficient evidence documenting evaluated stigma-reduction interventions. With stigma present in all life spheres, health facilities offer a logical starting point for developing and expanding stigma reduction interventions. This study evaluates the impact of a "total facility" stigma-reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana. METHODS We evaluated the impact of a total facility stigma-reduction intervention by comparing five intervention to five comparable non-intervention health facilities in Ghana. Interventions began in September 2017. Data collection was in June 2017 and April 2018. The primary outcomes were composite indicators for three stigma drivers, self-reported stigmatizing avoidance behaviour, and observed discrimination. The principal intervention variable was whether the respondent worked at an intervention or comparison facility. We estimated intervention effects as differences-in-differences in each outcome, further adjusted using inverse probability of treatment weighting (IPTW). RESULTS We observed favourable intervention effects for all outcome domains except for stigmatizing attitudes. Preferring not to provide services to people living with HIV (PLHIV) or a key population member improved 11.1% more in intervention than comparison facility respondents (95% CI 3.2 to 19.0). Other significant improvements included knowledge of policies to protect against discrimination (difference-in-differences = 20.4%; 95% CI 12.7 to 28.0); belief that discrimination would be punished (11.2%; 95% CI 0.2 to 22.3); and knowledge of and belief in the adequacy of infection control policies (17.6%; 95% CI 8.3 to 26.9). Reported observation of stigma and discrimination incidents fell by 7.4 percentage points more among intervention than comparison facility respondents, though only marginally significant in the IPTW-adjusted model (p = 0.06). Respondents at intervention facilities were 19.0% (95% CI 12.2 to 25.8) more likely to report that staff behaviour towards PLHIV had improved over the last year than those at comparison facilities. CONCLUSIONS These results provide a foundation for scaling up health facility stigma-reduction within national HIV responses, though they should be accompanied by rigorous implementation science to ensure ongoing learning and adaptation for maximum effectiveness and long-term impact.
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Affiliation(s)
- Laura Nyblade
- Global Health DivisionResearch Triangle Institute (RTI) InternationalWashingtonDCUSA
- Research Triangle Institute (RTI) InternationalResearch Triangle ParkNCUSA
| | - Nii A Addo
- Educational Assessment Research Centre (EARC)AccraGhana
| | | | | | - Emma Gyamera
- Educational Assessment Research Centre (EARC)AccraGhana
| | | | - Madeline Leonard
- Global Health DivisionResearch Triangle Institute (RTI) InternationalWashingtonDCUSA
- Department of Health Systems AdministrationGeorgetown UniversityWashingtonDCUSA
| | - Pia Mingkwan
- Global Health DivisionResearch Triangle Institute (RTI) InternationalWashingtonDCUSA
- Research Triangle Institute (RTI) InternationalResearch Triangle ParkNCUSA
| | - Christin Stewart
- Global Health DivisionResearch Triangle Institute (RTI) InternationalWashingtonDCUSA
- Research Triangle Institute (RTI) InternationalResearch Triangle ParkNCUSA
| | | | - John D Kraemer
- Global Health DivisionResearch Triangle Institute (RTI) InternationalWashingtonDCUSA
- Department of Health Systems AdministrationGeorgetown UniversityWashingtonDCUSA
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Li L, Lin C, Liang LJ, Chen J, Feng N, Nguyen AT. HIV- and Drug Use-Related Stigma and Service Provision Among Community Health Workers in Vietnam. AIDS EDUCATION AND PREVENTION : OFFICIAL PUBLICATION OF THE INTERNATIONAL SOCIETY FOR AIDS EDUCATION 2020; 32:169-179. [PMID: 32539482 PMCID: PMC8211404 DOI: 10.1521/aeap.2020.32.2.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This study compared community health workers' (CHW) stigma towards people living with HIV (PLH) and people who use drugs (PWUD) and explored the relationship between stigma and CHWs' confidence level in providing HIV/drug-related services. Using two sets of identically worded questions, levels of stigma towards PWUD and PLH were measured among 120 CHW from 60 communes in Vietnam. The associations between CHWs' confidence in service provision and stigma towards PWUD and PLH were examined using a linear mixed-effects regression model. The majority of the CHW reported higher levels of stigma towards PWUD than towards PLH. Compared to the CHW reporting higher stigma towards PWUD, those with higher stigma towards PLH were significantly less confident in service provision. Social opprobrium attached to drug-using behaviors can be a major driver behind the overall HIV stigma. CHWs' fear of HIV infection should be tackled to boost their confidence in HIV/drug-related care provision.
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Affiliation(s)
- Li Li
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, California
| | - Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, California
| | - Li-Jung Liang
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, California
| | - Jun Chen
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, California
| | - Nan Feng
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California, Los Angeles, California
| | - Anh Tuan Nguyen
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
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Sun S, Pachankis JE, Li X, Operario D. Addressing Minority Stress and Mental Health among Men Who Have Sex with Men (MSM) in China. Curr HIV/AIDS Rep 2020; 17:35-62. [PMID: 31950336 PMCID: PMC7050812 DOI: 10.1007/s11904-019-00479-w] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Men who have sex with men (MSM) in China experience elevated risks of mental health issues in comparison to the general population in China, which contribute to vulnerability to HIV/STI risks and can comprise the effectiveness of HIV prevention efforts. A conceptual framework for understanding this mental health disparity is minority stress theory, which posits that experiences of external prejudice events (i.e., distal stressors) and internal stress processes such as internalized homophobia and concealment (i.e., proximal stressors) contribute to sexual minorities' elevated risk of psychological distress. To deepen the understanding of mental health among Chinese MSM and explore the potential utility of minority stress theory in this population, this paper synthesizes research evidence regarding prevalent mental health issues as well as how minority stress may be linked to psychological health in Chinese MSM. RECENT FINDINGS Results indicate that Chinese MSM experience a high prevalence of several mental health issues including depression, anxiety, suicidal behaviors, and alcohol dependence. This review further reveals minority stress to be an important determinant of psychological distress among Chinese MSM, though evidence is mixed regarding the relationship between proximal minority stress and psychological health. Nonetheless, there is a lack of mental health services and interventions focusing on MSM in China. Culturally relevant, competent, and LGBT-affirmative mental health interventions are needed for Chinese MSM. To guide future intervention research, we provide considerations for reducing minority stress and promoting psychological health among Chinese MSM.
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Affiliation(s)
- Shufang Sun
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, 167 Point St, Providence, RI, 02906, USA.
| | - John E Pachankis
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Xiaoming Li
- Department of Health Promotion, Education, and Behavior, University of South Carolina Arnold School of Public Health, Columbia, SC, 29208, USA
| | - Don Operario
- Department of Behavioral and Social Sciences, Brown School of Public Health, Providence, RI, USA
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Liu C, Zhang Y, Pan SW, Cao B, Ong JJ, Fu H, Wu D, Fu R, Wei C, Tucker JD, Tang W. Anticipated HIV stigma among HIV negative men who have sex with men in China: a cross-sectional study. BMC Infect Dis 2020; 20:44. [PMID: 31941445 PMCID: PMC6961233 DOI: 10.1186/s12879-020-4778-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 01/08/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Anticipated HIV stigma, i.e., the expectation of adverse experiences from one's seroconversion, is associated with both negative psychological and behavioral outcomes. We know little about anticipated HIV stigma's relationship with emerging technologies, such as HIV self-testing (HIVST) and online sex-seeking platforms, that have become popular among populations that are disproportionately affected by HIV/AIDS. This study examined correlates of anticipated HIV stigma among Chinese men who have sex with men (MSM). METHODS In July 2016, MSM, who were ≥ 16 years old and self-reported as HIV negative or unknown, were recruited from a gay mobile phone application in China. Information regarding socio-demographics, sexual behaviors, sexual health service utilization, and anticipated HIV stigma were collected. Anticipated HIV stigma (i.e., negative attitude toward future stigmatization of HIV seroconversion by others) was measured as the mean score from a 7-item Likert-scale ranging from 1 (low) to 4 (high). Generalized linear models were conducted to examine the factors associated with the anticipated HIV stigma scores. RESULTS Overall, 2006 men completed the survey. Most men completed high school (1308/2006, 65.2%) and had an annual personal income of ≤9200 USD (1431/2006, 71.3%). The mean anticipated HIV stigma score for the participants was 2.98 ± 0.64. Using social media to seek sexual partners was associated with higher anticipated HIV stigma (Adjusted β = 0.11, 95% confidence interval (CI): 0.05 to 0.17, p = 0.001). HIV self-testing (Adjusted β = - 0.07, 95%CI: - 0.13 to - 0.01, p = 0.02) and having disclosed one's sexual orientation to a healthcare provider (Adjusted β = - 0.16, 95%CI: - 0.22 to - 0.96, p < 0.001) were associated with lower anticipated HIV stigma. CONCLUSION Our data suggested that anticipated HIV stigma is still common among Chinese MSM not living with HIV. Tailored anti-HIV stigma campaigns on social media are especially needed, and the promotion of HIVST may be a promising approach.
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Affiliation(s)
- Chuncheng Liu
- University of California San Diego, La Jolla, CA USA
- University of North Carolina Project-China, Guangzhou, China
| | - Ye Zhang
- University of North Carolina Project-China, Guangzhou, China
- Kirby Institution, UNSW, Sydney, Australia
| | - Stephen W. Pan
- University of North Carolina Project-China, Guangzhou, China
- Xi’an Jiaotong-Liverpool University, Suzhou, China
| | - Bolin Cao
- University of North Carolina Project-China, Guangzhou, China
- Shenzhen University, Shenzhen, China
| | - Jason J. Ong
- University of North Carolina Project-China, Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, UK
| | - Hongyun Fu
- University of North Carolina Project-China, Guangzhou, China
- Eastern Virginia Medical School, Norfolk, VA USA
| | - Dan Wu
- University of North Carolina Project-China, Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, UK
| | - Rong Fu
- University of North Carolina Project-China, Guangzhou, China
- Guangzhou CDC, Guangzhou, China
| | - Chongyi Wei
- University of North Carolina Project-China, Guangzhou, China
- Rutgers – The State University of New Jersey, New Brunswick, NJ USA
| | - Joseph D. Tucker
- University of North Carolina Project-China, Guangzhou, China
- London School of Hygiene and Tropical Medicine, London, UK
- Dermatology Hospital of Southern Medical University and the University of North Carolina Project-China, No.2 Lujing Road, Guangzhou, 510095 China
- University of North Carolina Chapel Hill, Chapel Hill, NC USA
| | - Weiming Tang
- Dermatology Hospital of Southern Medical University and the University of North Carolina Project-China, No.2 Lujing Road, Guangzhou, 510095 China
- University of North Carolina Chapel Hill, Chapel Hill, NC USA
- Institute of Global Health and STI Research, Southern Medical University, Guangzhou, China
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Hartog K, Hubbard CD, Krouwer AF, Thornicroft G, Kohrt BA, Jordans MJD. Stigma reduction interventions for children and adolescents in low- and middle-income countries: Systematic review of intervention strategies. Soc Sci Med 2019; 246:112749. [PMID: 31978636 DOI: 10.1016/j.socscimed.2019.112749] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 12/13/2019] [Accepted: 12/16/2019] [Indexed: 11/18/2022]
Abstract
Stigmatisation and discrimination are common worldwide, and have profound negative impacts on health and quality of life. Research, albeit limited, has focused predominantly on adults. There is a paucity of literature about stigma reduction strategies concerning children and adolescents, with evidence especially sparse for low- and middle-income countries (LMIC). This systematic review synthesised child-focused stigma reduction strategies in LMIC, and compared these to adult-focused interventions. Relevant publications were systematically searched in July and August 2018 in the following databases; Cochrane, Embase, Global Health, HMIC, Medline, PsycINFO, PubMed and WorldWideScience.org, and through Google Custom Search. Included studies and identified reviews were cross-referenced. Three categories of search terms were used: (i) stigma, (ii) intervention, and (iii) LMIC settings. Data on study design, participants and intervention details including strategies and implementation factors were extracted. Within 61 unique publications describing 79 interventions, utilising 14 unique stigma reduction strategies, 14 papers discussed 21 interventions and 10 unique strategies involving children. Most studies targeted HIV/AIDS (50% for children, 38% for adults) or mental illness (14% vs 34%) stigma. Community education (47%), individual empowerment (15%) and social contact (12%) were most employed in child-focused interventions. Most interventions were implemented at one socio-ecological level; child-focused interventions mostly employed community-level strategies (88%). Intervention duration was mostly short; between half a day and a week. Printed or movie-based material was key to deliver child-focused interventions (37%), while professionals most commonly implemented adult-focused interventions (53%). Ten unique, child-focused strategies were all evaluated positively, using a diverse set of scales. Children and adolescents are under-represented in stigma reduction in LMIC. More stigma reduction interventions in LMIC, addressing a wider variety of stigmas, with children as direct and indirect target group, are needed. This systematic review is registered under International Prospective Register of Systematic Reviews PROSPERO, reference number #CRD42018094700.
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Affiliation(s)
- Kim Hartog
- War Child Holland, Research and Development, Helmholzstraat 61-G, 1098, LE, Amsterdam, the Netherlands; Amsterdam Institute for Social Science Research, University of Amsterdam, Postbus 15718, 1001, NE, Amsterdam, the Netherlands.
| | - Carly D Hubbard
- London School of Hygiene and Tropical Medicine, Keppel St., Bloomsbury, London, WC1E, 7HT, United Kingdom.
| | - Angelica F Krouwer
- War Child Holland, Research and Development, Helmholzstraat 61-G, 1098, LE, Amsterdam, the Netherlands.
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute for Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, Camberwell, London, SE5 8AB, United Kingdom.
| | - Brandon A Kohrt
- Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington University, 2120 L Street, NW, Suite 600, Washington, DC, 20037, USA.
| | - Mark J D Jordans
- War Child Holland, Research and Development, Helmholzstraat 61-G, 1098, LE, Amsterdam, the Netherlands; Amsterdam Institute for Social Science Research, University of Amsterdam, Postbus 15718, 1001, NE, Amsterdam, the Netherlands.
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Lin C, Li L, Lee SJ, Chen L, Pan Y, Guan J. Using Conjoint Analysis to Investigate Hospital Directors' Preference in Adoption of an Evidence-based Intervention. INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2019; 14:328-334. [PMID: 34239710 DOI: 10.1080/20479700.2019.1645925] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study used conjoint analysis, a marketing research technique, to investigate hospital stakeholders' decision-making in adoption of evidence-based interventions (EBI). An efficacious hospital-based stigma-reduction intervention was used as a "product" to study adoption of EBI. Sixty hospital directors in Fujian, China evaluated the likelihood of adopting the EBI in their hospitals by rating across eight hypothetical scenarios with preferred and non-preferred levels of seven attributes, including 1) administrative support, 2) cost, 3) personnel involvement, 4) format, 5) duration, 6) technical support, and 7) priority alignment with the hospital. A hierarchical generalized linear model was fit to the likelihood of intervention adoption for the eight scenarios, with the seven attributes served as independent variables. Monetary cost of intervention implementation (impact score=2.12) had the greatest impact on the directors' reported likelihood of adopting the EBI, followed by duration of the intervention (impact score=0.88), availability of technical support (impact score=0.69), and flexibility of format (impact score=0.36). The impact scores of other attributes were not statistically significant. Conjoint analysis was feasible in modeling hospital directors' decision-making in adoption of EBI. The findings suggested the importance of considering cost, duration, technical support, and flexibility of format in development and dissemination of interventions in healthcare settings.
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Affiliation(s)
- Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles, Los Angeles, CA, U.S.A
| | - Li Li
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles, Los Angeles, CA, U.S.A
| | - Sung-Jae Lee
- Semel Institute for Neuroscience and Human Behavior, Center for Community Health, University of California at Los Angeles, Los Angeles, CA, U.S.A
| | - Liang Chen
- Fujian Provincial Center for Disease Control and Prevention, Fuzhou, China
| | - Yunjiao Pan
- Fujian Provincial Center for Disease Control and Prevention, Fuzhou, China
| | - Jihui Guan
- Fujian Provincial Center for Disease Control and Prevention, Fuzhou, China
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Flodgren G, O'Brien MA, Parmelli E, Grimshaw JM. Local opinion leaders: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2019; 6:CD000125. [PMID: 31232458 PMCID: PMC6589938 DOI: 10.1002/14651858.cd000125.pub5] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011. OBJECTIVES To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field. SELECTION CRITERIA We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs. DATA COLLECTION AND ANALYSIS We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention. MAIN RESULTS We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs. AUTHORS' CONCLUSIONS Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.
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Affiliation(s)
- Gerd Flodgren
- Norwegian Institute of Public HealthDivision of Health ServicesMarcus Thranes gate 6OsloNorway0403
| | - Mary Ann O'Brien
- University of TorontoDepartment of Family and Community Medicine500 University AvenueFifth FloorTorontoONCanadaM5G 1V7
| | - Elena Parmelli
- Lazio Regional Health Service ‐ ASL Roma1Department of EpidemiologyRomeItaly
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
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Stringer KL, Mukherjee T, McCrimmon T, Terlikbayeva A, Primbetovac S, Darisheva M, Hunt T, Gilbert L, El-Bassel N. Attitudes towards people living with HIV and people who inject drugs: A mixed method study of stigmas within harm reduction programs in Kazakhstan. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 68:27-36. [PMID: 30981165 PMCID: PMC6550278 DOI: 10.1016/j.drugpo.2019.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 01/16/2019] [Accepted: 02/25/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND High levels of stigma towards people who inject drugs (PWID) and people living with HIV (PLWH) exist in Kazakhstan, yet little is known about the role of stigma in harm reduction service settings. In this paper, we use a mixed method design to explore and describe the actionable drivers and facilitators of stigma among harm reduction service providers. Additionally, we describe the manifestations of stigma among PWID who are living with HIV (PWID/LWH), and the impact that stigma has on harm reduction and healthcare service utilization. METHODS Eight focus groups with 57 PWID/LWH were convened between March 2016 and July 2016 to describe manifestations of stigma from the perspective of syringe exchange program (SEP) clients. Additionally, we surveyed 80 nurses, social workers, outreach workers, and providers of HIV care at SEPs between January 2017 and July 2017 to assess stigmatizing attitudes among staff within the SEP environment. Joint displays were used to integrate quantitative and qualitative data. RESULTS The actionable drivers of stigma identified in this study include negative opinions and moral judgements towards PWID/LWH. Facilitators identified included stigmatization as a social norm within the service provision environment, a lack of awareness of anti-discrimination policies, and lack of enforcement of anti-discrimination policies. Qualitative findings highlight manifestations of stigma in which PWID/LWH experienced denial of services, perceived negative attitudes, and avoidance from service provision staff. PWID/LWH also described segregation in healthcare settings, the use of unnecessary precautions by providers, and unauthorized disclosure of HIV status. CONCLUSIONS This paper highlights the urgent need to address stigma in the harm reduction and HIV service settings in Kazakhstan. These findings have implications for informing an actionable model for stigma reduction for providers who deliver services to PWID/LWH in Kazakhstan. Drivers, facilitators, and manifestations of stigma are multifaceted and addressing them will require a multilevel approach.
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Affiliation(s)
| | - Trena Mukherjee
- Columbia University, Mailman School of Public Health, Department of Epidemiology, New York, NY, United States
| | - Tara McCrimmon
- Columbia University, Department of Social Work, New York, NY, United States
| | | | | | | | - Timothy Hunt
- Columbia University, Department of Social Work, New York, NY, United States
| | - Louisa Gilbert
- Columbia University, Department of Social Work, New York, NY, United States
| | - Nabila El-Bassel
- Columbia University, Department of Social Work, New York, NY, United States
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Abstract
PURPOSE OF REVIEW Adolescents and young people who fit within key populations face some of the greatest barriers to HIV care, but are frequently overlooked. We review the recent literature on these young, vulnerable populations including HIV risk factors, barriers to care, and strategies for engagement. RECENT FINDINGS Common risk factors include age, risky sexual practices, poor education, and high levels of alcohol and drug abuse. Barriers to care include limited data, criminalization, and high levels of stigma. Strategies to increase engagement include incorporating adolescents into biological and behavioral surveys and the use of social media. Digital innovations for HIV prevention and testing show promise, and pre-exposure prophylaxis may be acceptable. At a policy level, decriminalizing same-sex activity and commercial sex work are priorities. Differentiated models of care including HIV self-testing, after-hour services, community-based delivery, and multimonth dispensing of antiretroviral therapy, should be combined into holistic care. SUMMARY There has been limited success in reaching these key adolescent populations largely because of criminalization and stigma. Accurate, generalizable data are needed to inform the development of innovative strategies for holistic care.
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Affiliation(s)
- Morna Cornell
- Centre for Infectious Disease Epidemiology and Research
| | - Kathryn Dovel
- Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, United States of America
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Kemp CG, Jarrett BA, Kwon CS, Song L, Jetté N, Sapag JC, Bass J, Murray L, Rao D, Baral S. Implementation science and stigma reduction interventions in low- and middle-income countries: a systematic review. BMC Med 2019; 17:6. [PMID: 30764820 PMCID: PMC6376798 DOI: 10.1186/s12916-018-1237-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/10/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions to alleviate stigma are demonstrating effectiveness across a range of conditions, though few move beyond the pilot phase, especially in low- and middle-income countries (LMICs). Implementation science offers tools to study complex interventions, understand barriers to implementation, and generate evidence of affordability, scalability, and sustainability. Such evidence could be used to convince policy-makers and donors to invest in implementation. However, the utility of implementation research depends on its rigor and replicability. Our objectives were to systematically review implementation studies of health-related stigma reduction interventions in LMICs and critically assess the reporting of implementation outcomes and intervention descriptions. METHODS PubMed, CINAHL, PsycINFO, and EMBASE were searched for evaluations of stigma reduction interventions in LMICs reporting at least one implementation outcome. Study- and intervention-level characteristics were abstracted. The quality of reporting of implementation outcomes was assessed using a five-item rubric, and the comprehensiveness of intervention description and specification was assessed using the 12-item Template for Intervention Description and Replication (TIDieR). RESULTS A total of 35 eligible studies published between 2003 and 2017 were identified; of these, 20 (57%) used qualitative methods, 32 (91%) were type 1 hybrid effectiveness-implementation studies, and 29 (83%) were evaluations of once-off or pilot implementations. No studies adopted a formal theoretical framework for implementation research. Acceptability (20, 57%) and feasibility (14, 40%) were the most frequently reported implementation outcomes. The quality of reporting of implementation outcomes was low. The 35 studies evaluated 29 different interventions, of which 18 (62%) were implemented across sub-Saharan Africa, 20 (69%) focused on stigma related to HIV/AIDS, and 28 (97%) used information or education to reduce stigma. Intervention specification and description was uneven. CONCLUSION Implementation science could support the dissemination of stigma reduction interventions in LMICs, though usage to date has been limited. Theoretical frameworks and validated measures have not been used, key implementation outcomes like cost and sustainability have rarely been assessed, and intervention processes have not been presented in detail. Adapted frameworks, new measures, and increased LMIC-based implementation research capacity could promote the rigor of future stigma implementation research, helping the field deliver on the promise of stigma reduction interventions worldwide.
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Affiliation(s)
| | - Brooke A. Jarrett
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD USA
| | - Churl-Su Kwon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY USA
| | - Lanxin Song
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD USA
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY USA
| | - Jaime C. Sapag
- Departments of Public Health and Family Medicine, School of Medicine, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- Office of Transformative Global Health, Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON Canada
| | - Judith Bass
- Department of Mental Health, Johns Hopkins University, Baltimore, MD USA
| | - Laura Murray
- Department of Mental Health, Johns Hopkins University, Baltimore, MD USA
| | - Deepa Rao
- Department of Global Health, University of Washington, Seattle, WA USA
| | - Stefan Baral
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD USA
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Feyissa GT, Lockwood C, Woldie M, Munn Z. Reducing HIV-related stigma and discrimination in healthcare settings: A systematic review of quantitative evidence. PLoS One 2019; 14:e0211298. [PMID: 30682131 PMCID: PMC6347272 DOI: 10.1371/journal.pone.0211298] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/10/2019] [Indexed: 12/20/2022] Open
Abstract
Introduction Stigma and discrimination (SAD) related to HIV compromise access and adherence to treatment and support programs among people living with HIV (PLHIV). The ambitious goal of ending the epidemic of HIV by 2030 set by the United Nations Joint Program of HIV/AIDS (UNAIDS) will thus only be achieved if HIV-related stigma and discrimination are reduced. The objective of this review was to locate, appraise and describe international literature reporting on interventions that addressed HIV-related SAD in healthcare settings. Methods The databases searched were: Cumulative Index to Nursing and Allied Health (CINAHL), Excerpta Medica Database from Elsevier (EMBASE), PubMed and Psychological Information (PsycINFO) database. Two individuals independently appraised the quality of the papers using appraisal instruments from the Joanna Briggs Institute (JBI). Data were extracted from papers included in the review using the standardized data extraction tool from JBI. Quality of evidence for major outcomes was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). Results We retained 14 records reporting on eight studies. Five categories of SAD reduction (information-based, skills building, structural, contact-based and biomedical interventions) were identified. Training popular opinion leaders (POLs) resulted in significantly lower mean avoidance intent scores (MD = -1.87 [95% CI -2.05 to -1.69]), mean prejudicial attitude scores (MD = -3.77 [95% CI -5.4 to -2.09]) and significantly higher scores in mean compliance to universal precaution (MD = 1.65 [95% CI 1.41 to 1.89]) when compared to usual care (moderate quality evidence). The Summary of Findings table (SOF) is shown in Table 1. Conclusions Evidence of moderate quality indicates that training popular opinion leaders is effective in reducing avoidance intent and prejudicial attitude and improving compliance to universal precaution. Very low quality evidence indicates that professionally-assisted peer group interventions, modular interactive training, participatory self-guided assessment and intervention, contact strategy combined with information giving and empowerment are effective in reducing HIV-related stigma.Further Randomized Controlled Trials (RCTs) are needed. Future trials need to use up-to-date and validated instruments to measure stigma and discrimination.
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Affiliation(s)
- Garumma Tolu Feyissa
- Jimma University, Department of Health, Behavior and Society, Jimma, Ethiopia
- Ethiopian Evidence Based Health Care Centre: JBI Center of Excellence, Jimma University, Jimma, Ethiopia
- The Joanna Briggs Institute, the University of Adelaide, Adelaide, Australia
- * E-mail:
| | - Craig Lockwood
- The Joanna Briggs Institute, the University of Adelaide, Adelaide, Australia
| | - Mirkuzie Woldie
- Ethiopian Evidence Based Health Care Centre: JBI Center of Excellence, Jimma University, Jimma, Ethiopia
- Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
- Department of Global Health and Population, T.H. Chan Harvard School of Public Health, Addis Ababa, Ethiopia
| | - Zachary Munn
- The Joanna Briggs Institute, the University of Adelaide, Adelaide, Australia
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Ekstrand ML, Heylen E, Mazur A, Steward WT, Carpenter C, Yadav K, Sinha S, Nyamathi A. The Role of HIV Stigma in ART Adherence and Quality of Life Among Rural Women Living with HIV in India. AIDS Behav 2018; 22:3859-3868. [PMID: 29789984 DOI: 10.1007/s10461-018-2157-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
HIV stigma continues to be a barrier to physical and mental health among people living with HIV globally, especially in vulnerable populations. We examined how stigma is associated with health outcomes and quality of life among rural women living with HIV in South India (N = 600). Interviewer-administered measures assessed multiple dimensions of stigma, as well as loneliness, social support, ART adherence, time since diagnosis, and quality of life. Internalized stigma and a lack of social support were associated with a lower quality of life, while the association between internalized stigma and adherence was mediated by the use of stigma-avoidant coping strategies, suggesting that keeping one's diagnosis a secret may make it more difficult to take one's medications. These findings suggest that these women constitute a vulnerable population who need additional services to optimize their health and who might benefit from peer support interventions and stigma-reduction programs for family and community members.
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Affiliation(s)
- Maria L Ekstrand
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA.
- St John's Research Institute, Bangalore, India.
| | - Elsa Heylen
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | - Amanda Mazur
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | - Wayne T Steward
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | | | | | - Sanjeev Sinha
- All India Institute of Medical Sciences, New Delhi, India
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Mulawa MI, Yamanis TJ, Kajula LJ, Balvanz P, Maman S. Structural Network Position and Performance of Health Leaders Within an HIV Prevention Trial. AIDS Behav 2018; 22:3033-3043. [PMID: 29705931 DOI: 10.1007/s10461-018-2126-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The effectiveness of peer leaders in promoting health may depend on the position they occupy within their social networks. Using sociocentric (whole network) and behavioral data from the intervention arm of a cluster-randomized HIV prevention trial in Dar es Salaam, Tanzania, we used generalized linear models with standardized predictors to examine the association between heath leaders' baseline structural network position (i.e., in-degree and betweenness centrality) and their 12-month self-reported (1) confidence in educating network members about HIV and gender-based violence (GBV) and (2) number of past-week conversations about HIV and GBV. As in-degree centrality increased, leaders reported fewer HIV-related conversations. As betweenness centrality increased, leaders reported greater number of conversations about GBV. Network position was not significantly associated with confidence in discussing either topic. Our results suggest that peer leaders who occupy spaces between sub-groups of network members may be more effective in engaging their peers in sensitive or controversial topics like GBV than more popular peer leaders.
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Rau A, Wouters E, Engelbrecht M, Masquillier C, Uebel K, Kigozi G, Sommerland N, Janse van Rensburg A. Towards a health-enabling working environment - developing and testing interventions to decrease HIV and TB stigma among healthcare workers in the Free State, South Africa: study protocol for a randomised controlled trial. Trials 2018; 19:351. [PMID: 29973259 PMCID: PMC6031140 DOI: 10.1186/s13063-018-2713-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 06/01/2018] [Indexed: 11/10/2022] Open
Abstract
Background Occupational exposure to tuberculosis (TB) constitutes a major health risk for healthcare workers (HCWs). The HIV epidemic equally affects the workforce because of the mutually reinforcing epidemiology of HIV and TB. Stigmas associated with HIV and TB have become so intricately entangled that they stop some HCWs from seeking care in a context where serious shortages in human resources for health besiege public health facilities. It is thus imperative to research, as well as attempt to tackle, HIV and TB stigma among HCWs. But little has been done internationally—and nationally, only our own exploratory studies. Our project aims to address this by (1) scientifically assessing the extent and sources of HIV and TB-related stigma among HCWs and (2) developing and testing evidence-based, stigma-reduction interventions in public hospitals in the Free State Province of South Africa. Methods/design The research follows a stratified cluster randomised controlled trial (RCT) design. Pre intervention, a self-administered questionnaire with the pilot study’s validated stigma scales is used to measure stigma and other key variables among randomly selected HCWs in eight hospitals—stratified by size and district and then randomly allocated to four intervention and four control sites. Interventions comprise HIV- and TB-stigma reduction activities—mainly Social and Behavioural Change Communication (SBCC) interventions—at three social-ecology levels (individual, community, and socio-structural). An outside assessor will appraise the trial mid-way through implementation. Post intervention, all baseline respondents will be followed up to complete the baseline questionnaire with additional items on interventions. Qualitative data will be collected to better understand HIV and TB stigma and explore if, and how, interventions impact stigma levels in the workplace. Discussion The study regards as HCWs all staff, working in all different types of jobs, at all levels in the hospitals. Thus, the research addresses HIV and TB stigma across the whole workforce and the entire workplace. In doing so it will (1) generate essential information on stigma among HCWs and (2) implement stigma-reduction interventions that are innovative yet replicable, and potentially beneficial in addressing a pernicious human-rights-based issue. Trial registration South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2713-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Asta Rau
- University of the Free State (UFS), Centre for Health Systems Research & Development (CHSR&D), Faculty of the Humanities, PO Box 339, Bloemfontein, 9300, South Africa.
| | - Edwin Wouters
- University of the Free State (UFS), Centre for Health Systems Research & Development (CHSR&D), Faculty of the Humanities, PO Box 339, Bloemfontein, 9300, South Africa.,Department of Sociology, University of Antwerp (AU), Research Centre for Longitudinal & Life Course Studies (CELLO), Faculty of Political and Social Sciences, Sint-Jacobstraat 2, BE-2000, Antwerp, Belgium
| | - Michelle Engelbrecht
- University of the Free State (UFS), Centre for Health Systems Research & Development (CHSR&D), Faculty of the Humanities, PO Box 339, Bloemfontein, 9300, South Africa
| | - Caroline Masquillier
- Department of Sociology, University of Antwerp (AU), Research Centre for Longitudinal & Life Course Studies (CELLO), Faculty of Political and Social Sciences, Sint-Jacobstraat 2, BE-2000, Antwerp, Belgium
| | - Kerry Uebel
- University of the Free State (UFS), Centre for Health Systems Research & Development (CHSR&D), Faculty of the Humanities, PO Box 339, Bloemfontein, 9300, South Africa.,Department of Internal Medicine, School of Medicine, Faculty of Health Sciences, University of the Free State (UFS), PO Box 339, Bloemfontein, 9300, South Africa
| | - Gladys Kigozi
- University of the Free State (UFS), Centre for Health Systems Research & Development (CHSR&D), Faculty of the Humanities, PO Box 339, Bloemfontein, 9300, South Africa
| | - Nina Sommerland
- Department of Sociology, University of Antwerp (AU), Research Centre for Longitudinal & Life Course Studies (CELLO), Faculty of Political and Social Sciences, Sint-Jacobstraat 2, BE-2000, Antwerp, Belgium
| | - André Janse van Rensburg
- University of the Free State (UFS), Centre for Health Systems Research & Development (CHSR&D), Faculty of the Humanities, PO Box 339, Bloemfontein, 9300, South Africa
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Nyblade L, Srinivasan K, Mazur A, Raj T, Patil DS, Devadass D, Radhakrishna K, Ekstrand ML. HIV Stigma Reduction for Health Facility Staff: Development of a Blended- Learning Intervention. Front Public Health 2018; 6:165. [PMID: 29977887 PMCID: PMC6021510 DOI: 10.3389/fpubh.2018.00165] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 05/17/2018] [Indexed: 12/25/2022] Open
Abstract
Introduction: The effect of stigma on health and health inequity is increasingly recognized. While many medical conditions trigger stigmatization, the negative effects of HIV stigma are particularly well documented. HIV stigma undermines access, uptake, and adherence to both HIV prevention and treatment. People living with HIV face stigma in all aspects of their daily lives; however, stigma in the health system is particularly detrimental. A key component for health facility stigma-reduction interventions is participatory training of staff, often through several days of in-person training. Though this approach shows promise, it is time intensive and poses challenges for busy health facilities. In response, the DriSti study has developed a brief blended-learning approach to stigma reduction in Karnataka State, India. This paper describes the process and final content of the intervention development. The intervention is currently being tested. Final evaluation results will be published upon study completion. Methods: Grounded in behavior change strategies based on social cognitive theory principles that stress the importance of combining interpersonal interactions with specific strategies that promote behavior change, we used a three-phase approach to intervention development: (1) content planning—review of existing participatory stigma-reduction training activities; (2) story boarding—script development and tablet content production; and (3) pilot testing of tablet and in-person session materials. Results: The final intervention curriculum consists of three sessions. Two initial self-administered tablet sessions focus on stigma awareness, attitudes, fears of HIV transmission, and use of standard precautions. The third small group session covers the same material but includes skill building through role-play and testimony by a person living with HIV. A study team member administers the tablet sessions, explains the process, and is present throughout to answer questions. Conclusion: This paper describes the theoretical underpinning and process of developing the blended-learning curriculum content, and practical lessons learned.The approach covers three key drivers of HIV stigma—stigma awareness, fear of HIV transmission, and attitudes. Developing video content for the self-directed learning is complex, requires a diverse set of people and skills, and presents unexpected opportunities for stigma reduction. Co-facilitation of the in-person session by someone living with HIV is a critical component.
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Affiliation(s)
- Laura Nyblade
- Global Health Division, International Development Group, RTI International, Washington, DC, United States
| | | | - Amanda Mazur
- Department of Medicine, Center for AIDS Prevention Studies, San Francisco, CA, United States
| | - Tony Raj
- St. Johns Research Institute, Bangalore, India
| | | | | | | | - Maria L Ekstrand
- St. Johns Research Institute, Bangalore, India.,Department of Medicine, Center for AIDS Prevention Studies, San Francisco, CA, United States
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Lin C, Tuan NA, Li L. Commune Health Workers' Methadone Maintenance Treatment (MMT) Knowledge and Perceived Difficulties Providing Decentralized MMT Services in Vietnam. Subst Use Misuse 2018; 53:194-199. [PMID: 28704128 PMCID: PMC5758416 DOI: 10.1080/10826084.2017.1310248] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND With the initial establishment of countrywide methadone maintenance therapy (MMT) system, Vietnam is in the process of expanding and decentralizing the MMT program to community-based healthcare settings. OBJECTIVE The study aimed to measure the MMT-related knowledge and perceived difficulties in treating patient who use drugs (PWUD) among community-based healthcare providers, e.g., commune health workers (CHW), and examine its correlated factors. METHODS A total of 300 CHW from 60 communes in two provinces of Vietnam completed a survey using Audio Computer-Assisted Self-Interview (ACASI) method. Twelve true-or-false questions were used to assess the CHW's MMT-related knowledge. The CHW's background characteristics and perceived difficulties treating PWUD were recorded. RESULTS The mean MMT knowledge score was 8.2 (SD = 1.2; range: 5-11). Misconceptions toward the benefits, procedure, and side effects of MMT were prevalent. The participants perceived varying degrees of difficulties in recruiting, engaging, and communicating with PWUD. With all covariates holding constant, younger age (standardized ẞ = -0.166; p = 0.0078) was associated with less MMT-related knowledge. Number of PWUD seen in a month and MMT-related knowledge was associated with less perceived difficulties treating PWUD. Conclusions/importance: The finding shed lights on the CHW's knowledge gap, which need to be addressed to facilitate the decentralization of MMT services in Vietnam. In preparation for a decentralized MMT service delivery model, specially designed training is warranted to equip CHW with knowledge and confidence to provide MMT-related services to PWUD.
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Affiliation(s)
- Chunqing Lin
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health , University of California , Los Angeles , California , USA
| | - Nguyen Anh Tuan
- b National Institute of Hygiene and Epidemiology , Hanoi , Vietnam
| | - Li Li
- a Semel Institute for Neuroscience and Human Behavior, Center for Community Health , University of California , Los Angeles , California , USA
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43
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Zeng C, Li L, Hong YA, Zhang H, Babbitt AW, Liu C, Li L, Qiao J, Guo Y, Cai W. A structural equation model of perceived and internalized stigma, depression, and suicidal status among people living with HIV/AIDS. BMC Public Health 2018; 18:138. [PMID: 29334959 PMCID: PMC5769512 DOI: 10.1186/s12889-018-5053-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 01/10/2018] [Indexed: 12/03/2022] Open
Abstract
Background Previous studies have shown positive association between HIV-related stigma and depression, suicidal ideation, and suicidal attempt among people living with HIV/AIDS (PLWH). But few studies have examined the mechanisms among HIV-related stigma, depression, and suicidal status (suicidal ideation and/or suicidal attempt) in PLWH. The current study examined the relationships among perceived and internalized stigma (PIS), depression, and suicidal status among PLWH in Guangzhou, China using structural equation modeling. Methods Cross-sectional study by convenience sampling was conducted and 411 PLWH were recruited from the Number Eight People’s Hospital from March to June, 2013 in Guangzhou, China. Participants were interviewed on their PIS, depressive symptoms, suicidal status, and socio-demographic characteristics. PLWH who had had suicidal ideation and suicidal attempts since HIV diagnosis were considered to be suicidal. Structural equation model was performed to examine the direct and indirect associations of PIS and suicidal status. Indicators to evaluate goodness of fit of the structural equation model included Chi-square Statistic, Comparative Fit Index (CFI), Root Mean Square Error of Approximation (RMSEA), Standardized Root Mean Square Residual (SRMR), and Weighted Root Mean Square Residual (WRMR). Results More than one-third (38.4%) of the PLWH had depressive symptoms and 32.4% reported suicidal ideation and/or attempt since HIV diagnosis. The global model showed good model fit (Chi-square value = 34.42, CFI = 0.98, RMSEA = 0.03, WRMR = 0.73). Structural equation model revealed that direct pathway of PIS on suicidal status was significant (standardized pathway coefficient = 0.21), and indirect pathway of PIS on suicidal status via depression was also significant (standardized pathway coefficient = 0.24). There was a partial mediating effect of depression in the association between PIS and suicidal status. Conclusions Our findings suggest that PIS is associated with increased depression and the likelihood of suicidal status. Depression is in turn positively associated with suicidal status and plays a mediating role between PIS and suicidal status. Therefore, to reduce suicidal ideation and attempt in PLWH, targeted interventions to reduce PIS and improve mental health status of PLWH are warranted.
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Affiliation(s)
- Chengbo Zeng
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Linghua Li
- Department of Infectious Disease, Guangzhou Number Eight People's Hospital, #627 Dongfeng Road, Guangzhou, 510080, China
| | - Yan Alicia Hong
- Department of Health Promotion and Community Health Sciences, School of Public Health, Health Science Center, Texas A&M University, College Station, TX, 77843, USA
| | - Hanxi Zhang
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Andrew Walker Babbitt
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Cong Liu
- Department of Infectious Disease, Guangzhou Number Eight People's Hospital, #627 Dongfeng Road, Guangzhou, 510080, China
| | - Lixia Li
- Department of Epidemiology and Health Statistics, School of Public Health, Guangdong Pharmaceutical University, #283 Jianghai Street, Guangzhou, 510220, China
| | - Jiaying Qiao
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Yan Guo
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, #74 Zhongshan 2nd Road, Guangzhou, 510080, China. .,Sun Yat-sen Center for Migrant Health Policy, Sun Yat-sen University, Guangzhou, China. .,Sun Yat-sen Global Health Institute, Institute of State Governance, Sun Yat-sen University, Guangzhou, China.
| | - Weiping Cai
- Department of Infectious Disease, Guangzhou Number Eight People's Hospital, #627 Dongfeng Road, Guangzhou, 510080, China.
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Shacham E, López JD, Brown TM, Tippit K, Ritz A. Enhancing Adherence to Care in the HIV Care Continuum: The Barrier Elimination and Care Navigation (BEACON) Project Evaluation. AIDS Behav 2018; 22:258-264. [PMID: 28597342 DOI: 10.1007/s10461-017-1819-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Interventions are needed to address each phase of the HIV care continuum in order to improve health outcomes and reduce likelihood of HIV transmission. The purpose of this study was to assess the impact of a community- and clinic-based intervention designed and implemented to reengage individuals who were lost to HIV care. Eligible participants had either never engaged in HIV care or had not had a medical visit for at least 12 months. Participants enrolled in a community- and clinic-based intervention that included intensive case management, access to a community nurse and peer navigator, as well as emergency stabilization funds. Data were collected at baseline and 6-month time points by the case managers; which included sociodemographics, general health, abstracted HIV viral loads and CD4 cell counts from their medical records. Descriptive and GEE analyses were conducted to assess changes from baseline to 6 months. A total of 322 participants enrolled over a 5-year period, of whom the majority were male (n = 250) and African American with a mean age of 42.0 years. After 6 months of the intervention, there was a significant increase of individuals who had undetectable HIV viral loads and their median CD4 cell counts increased (p < 0.01 for both). General health improved as well (p < 0.01). It is clear that this method of engagement, while staff intensive, is successful at engaging and retaining individuals in HIV care at least through 6 months.
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45
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Wu S, Roychowdhury I, Khan M. Evaluations of training programs to improve human resource capacity for HIV, malaria, and TB control: a systematic scoping review of methods applied and outcomes assessed. Trop Med Health 2017; 45:16. [PMID: 28680324 PMCID: PMC5493875 DOI: 10.1186/s41182-017-0056-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/16/2017] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Owing to the global health workforce crisis, more funding has been invested in strengthening human resources for health, particularly for HIV, tuberculosis, and malaria control; however, little is known about how these investments in training are evaluated. This paper examines how frequently HIV, malaria, and TB healthcare provider training programs have been scientifically evaluated, synthesizes information on the methods and outcome indicators used, and identifies evidence gaps for future evaluations to address. METHODS We conducted a systematic scoping review of publications evaluating postgraduate training programs, including in-service training programs, for HIV, tuberculosis, and malaria healthcare providers between 2000 and 2016. Using broad inclusion criteria, we searched three electronic databases and additional gray literature sources. After independent screening by two authors, data about the year, location, methodology, and outcomes assessed was extracted from eligible training program evaluation studies. Training outcomes evaluated were categorized into four levels (reaction, learning, behavior, and results) based on the Kirkpatrick model. FINDINGS Of 1473 unique publications identified, 87 were eligible for inclusion in the analysis. The number of published articles increased after 2006, with most (n = 57, 66%) conducted in African countries. The majority of training evaluations (n = 44, 51%) were based on HIV with fewer studies focused on malaria (n = 28, 32%) and TB (n = 23, 26%) related training. We found that quantitative survey of trainees was the most commonly used evaluation method (n = 29, 33%) and the most commonly assessed outcomes were knowledge acquisition (learning) of trainees (n = 44, 51%) and organizational impacts of the training programs (38, 44%). Behavior change and trainees' reaction to the training were evaluated less frequently and using less robust methods; costs of training were also rarely assessed. CONCLUSIONS Our study found that a limited number of robust evaluations had been conducted since 2000, even though the number of training programs has increased over this period to address the human resource shortage for HIV, malaria, and TB control. Specifically, we identified a lack evaluation studies on TB- and malaria-related healthcare provider training and very few studies assessing behavior change of trainees or costs of training. Developing frameworks and standardized evaluation methods may facilitate strengthening of the evidence base to inform policies on and investments in training programs.
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Affiliation(s)
- Shishi Wu
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Imara Roychowdhury
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore
| | - Mishal Khan
- Saw Swee Hock School of Public Health, National University of Singapore, 12 Science Drive 2 #10-01, Singapore, 117549 Singapore.,Communicable Diseases Policy Research Group, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT United Kingdom
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46
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Nyblade L, Reddy A, Mbote D, Kraemer J, Stockton M, Kemunto C, Krotki K, Morla J, Njuguna S, Dutta A, Barker C. The relationship between health worker stigma and uptake of HIV counseling and testing and utilization of non-HIV health services: the experience of male and female sex workers in Kenya. AIDS Care 2017; 29:1364-1372. [PMID: 28325068 DOI: 10.1080/09540121.2017.1307922] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The barrier HIV-stigma presents to the HIV treatment cascade is increasingly documented; however less is known about female and male sex worker engagement in and the influence of sex-work stigma on the HIV care continuum. While stigma occurs in all spheres of life, stigma within health services may be particularly detrimental to health seeking behaviors. Therefore, we present levels of sex-work stigma from healthcare workers (HCW) among male and female sex workers in Kenya, and explore the relationship between sex-work stigma and HIV counseling and testing. We also examine the relationship between sex-work stigma and utilization of non-HIV health services. A snowball sample of 497 female sex workers (FSW) and 232 male sex workers (MSW) across four sites was recruited through a modified respondent-driven sampling process. About 50% of both male and female sex workers reported anticipating verbal stigma from HCW while 72% of FSW and 54% of MSW reported experiencing at least one of seven measured forms of stigma from HCW. In general, stigma led to higher odds of reporting delay or avoidance of counseling and testing, as well as non-HIV specific services. Statistical significance of relationships varied across type of health service, type of stigma and gender. For example, anticipated stigma was not a significant predictor of delay or avoidance of health services for MSW; however, FSW who anticipated HCW stigma had significantly higher odds of avoiding (OR = 2.11) non-HIV services, compared to FSW who did not. This paper adds to the growing evidence of stigma as a roadblock in the HIV treatment cascade, as well as its undermining of the human right to health. While more attention is being paid to addressing HIV-stigma, it is equally important to address the key population stigma that often intersects with HIV-stigma.
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Affiliation(s)
- Laura Nyblade
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | - Aditi Reddy
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | | | - John Kraemer
- a Global Health Division, International Development Group , RTI International , Washington , USA.,c Department of Health Systems Administration , Georgetown University , Washington , USA
| | - Melissa Stockton
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | | | - Karol Krotki
- a Global Health Division, International Development Group , RTI International , Washington , USA
| | - Javier Morla
- a Global Health Division, International Development Group , RTI International , Washington , USA
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Stigma Reduction Training Improves Healthcare Provider Attitudes Toward, and Experiences of, Young Marginalized People in Bangladesh. J Adolesc Health 2017; 60:S35-S44. [PMID: 28109339 DOI: 10.1016/j.jadohealth.2016.09.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 09/15/2016] [Accepted: 09/28/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE Working with health providers to reduce HIV stigma in the healthcare setting is an important strategy to improve service utilization and quality of care, especially for young people who are sexually active before marriage, are sexual minorities, or who sell sex. A stigma reduction training program for health providers in Bangladesh was evaluated. METHODS A cohort of 300 healthcare providers were given a self-administered questionnaire, then attended a 2-day HIV and sexual and reproductive health and rights training (including a 90-minute session on stigma issues). Six months later, the cohort repeated the survey and participated in a 1-day supplemental training on stigma, which included reflection on personal values and negative impacts of stigma. A third survey was administered 6 months later. A cross-sectional survey of clients age 15-24 years was implemented before and after the second stigma training to assess client satisfaction with services. RESULTS Provider agreement that people living with HIV should be ashamed of themselves decreased substantially (35.3%-19.7%-16.3%; p < .001), as did agreement that sexually active young people (50.3%-36.0%-21.7%; p < .001) and men who have sex with men (49.3%-38.0%-24.0%; p < .001) engage in "immoral behavior." Young clients reported improvement in overall satisfaction with services after the stigma trainings (63.5%-97.6%; p < .001). CONCLUSIONS This study indicates that a targeted stigma reduction intervention can rapidly improve provider attitudes and increase service satisfaction among young people. More funding to scale up these interventions is needed.
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Batey DS, Whitfield S, Mulla M, Stringer KL, Durojaiye M, McCormick L, Turan B, Nyblade L, Kempf MC, Turan JM. Adaptation and Implementation of an Intervention to Reduce HIV-Related Stigma Among Healthcare Workers in the United States: Piloting of the FRESH Workshop. AIDS Patient Care STDS 2016; 30:519-527. [PMID: 27849373 DOI: 10.1089/apc.2016.0223] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
HIV-related stigma has been shown to have profound effects on people living with HIV (PLWH). When stigma is experienced in a healthcare setting, negative health outcomes are exacerbated. We sought to assess the feasibility and acceptability of a healthcare setting stigma-reduction intervention, the Finding Respect and Ending Stigma around HIV (FRESH) Workshop, in the United States. This intervention, adapted from a similar strategy implemented in Africa, brought together healthcare workers (HW) and PLWH to address HIV-related stigma. Two pilot workshops were conducted in Alabama and included 17 HW and 19 PLWH. Participants completed questionnaire measures pre- and post-workshop, including open-ended feedback items. Analytical methods included assessment of measures reliability, pre-post-test comparisons using paired t-tests, and qualitative content analysis. Overall satisfaction with the workshop experience was high, with 87% PLWH and 89% HW rating the workshop "excellent" and the majority agreeing that others like themselves would be interested in participating. Content analysis of open-ended items revealed that participants considered the workshop informative, interactive, well-organized, understandable, fun, and inclusive, while addressing real and prevalent issues. Most pre- and post-test measures had good-excellent internal consistency reliability (Cronbach's alphas ranging from 0.70 to 0.96) and, although sample sizes were small, positive trends were observed, reaching statistical significance for increased awareness of stigma in the health facility among HW (p = 0.047) and decreased uncertainty about HIV treatment among PLWH (p = 0.017). The FRESH intervention appears to be feasible and highly acceptable to HW and PLWH participants and shows great promise as a healthcare setting stigma-reduction intervention for US contexts.
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Affiliation(s)
- D. Scott Batey
- Department of Social Work, College of Arts & Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - Samantha Whitfield
- Healthcare Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mazheruddin Mulla
- Department of Psychology, College of Arts & Sciences, The University of Alabama, Tuscaloosa, Alabama
| | - Kristi L. Stringer
- Department of Sociology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Modupeoluwa Durojaiye
- Healthcare Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisa McCormick
- Healthcare Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Bulent Turan
- Department of Psychology, College of Arts & Sciences, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura Nyblade
- Division of Global Health, International Development Group and HP+, RTI International, Washington, District of Columbia
| | - Mirjam-Colette Kempf
- Nursing Family, Community & Health Systems, College of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Janet M. Turan
- Healthcare Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
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Wang K, Chen WT, Zhang L, Bao M, Zhao H, Lu H. Facilitators of and barriers to HIV self-management: Perspectives of HIV-positive women in China. Appl Nurs Res 2016; 32:91-97. [PMID: 27969059 PMCID: PMC5158022 DOI: 10.1016/j.apnr.2016.06.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/21/2016] [Accepted: 06/07/2016] [Indexed: 01/09/2023]
Abstract
AIMS The aim is to explore perceived facilitators of and barriers to HIV self-management for HIV-positive Chinese women. BACKGROUND Little is known about self-management among HIV-positive Chinese women in China. Understanding the experiences of this population is needed to promote self-management. METHODS 27 in-depth interviews were conducted in Beijing and Shanghai. Facilitators included families being supportive after disclosure, patients learning how to live with HIV, antiretroviral therapy (ART) adherence, and rediscovering the meaning of life. Several barriers were also identified, including lack of support, stigma, fatigue, and financial difficulty. RESULTS HIV disclosure is essential to obtaining necessary support. Ironically, disclosing to family members who stigmatize the disease may invite unwelcome responses. Helping HIV-positive women to decrease self-stigma and develop an effective way to disclose, if they choose to, is important. CONCLUSION Future interventions should focus on disclosure strategies development and self-management to prevent isolation, enhance social support, and decrease self-stigma.
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Affiliation(s)
- Kerong Wang
- HIV/AIDS Unit, Beijing Ditan Hospital, Capital Medical University, Beijing 100050, China
| | - Wei-Ti Chen
- School of Nursing, Yale University, Orange, CT 06477, USA
| | - Lin Zhang
- Departemnt of Nursing, Shanghai Public Health Clinical Center, Shanghai 201508, China
| | - MeiJuan Bao
- Departemnt of Nursing, Shanghai Public Health Clinical Center, Shanghai 201508, China
| | - Hongxin Zhao
- HIV/AIDS Unit, Beijing Ditan Hospital, Capital Medical University, Beijing 100050, China.
| | - Hongzhou Lu
- Departemnt of Nursing, Shanghai Public Health Clinical Center, Shanghai 201508, China.
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50
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Operario D, Wang D, Zaller ND, Yang MF, Blaney K, Cheng J, Hong Q, Zhang H, Chai J, Szekeres G, Galea J, Coates TJ. Effect of a knowledge-based and skills-based programme for physicians on risk of sexually transmitted reinfections among high-risk patients in China: a cluster randomised trial. LANCET GLOBAL HEALTH 2016; 4:e29-36. [PMID: 26718807 DOI: 10.1016/s2214-109x(15)00249-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 09/22/2015] [Accepted: 10/19/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND China is experiencing growing epidemics of HIV and sexually transmitted infections (STIs). Programmes to train physicians in China on HIV and STI knowledge, diagnosis, treatment, and risk reduction counselling can potentially reduce HIV and STI risk among high-risk patients. We aimed to assess a knowledge-based and skills-based programme for physicians in China to reduce patients' STI risk. METHODS In this cluster randomised trial, we block randomised counties in two provinces in eastern China to intervention or control groups. In the intervention group, physicians from county general hospitals participated in a structured HIV and STI training programme and received opportunities to enhance their clinical and counselling skills, whereas in the control group, physicians from county hospitals received the training after the intervention group completed final assessments. We recruited STI patients from physicians in both groups, treated baseline gonorrhoea and chlamydia infections, and assessed 9-month gonorrhoea and chlamydia reinfection as the primary outcome. Statistical comparisons between intervention and delayed-control patients used multilevel analyses to account for cluster effects at county and physician levels. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, NCT00644150. FINDINGS Between April 1, 2007, and Sept 1, 2008, 51 counties were randomly assigned; 27 to receive immediate intervention and 24 to receive delayed intervention. 249 physicians from the 51 county-level hospitals were enrolled, 121 physicians in the intervention group and 128 in the control group. From these physicians, we enrolled 633 and 491 patients, respectively, of whom 508 (80%) and 402 (82%) were available for reassessment at 9 months. Intervention patients at follow-up had significantly lower odds of combined gonorrhoea or chlamydia reinfection than did control patients (58/508 [11%] vs 123/402 [31%]; adjusted odds ratio 0·62 [95% CI 0·46-0·84]). INTERPRETATION Integrating HIV and STI training into medical education in China could be an effective strategy to reduce the country's growing HIV risk and STI epidemics. FUNDING US National Institutes of Health.
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Affiliation(s)
| | - Debin Wang
- School of Health Service Management, Anhui Medical University, China
| | - Nickolas D Zaller
- Fay Boozman College of Public Health, University of Arkansas, Fayetteville, AR, USA
| | | | | | - Jing Cheng
- School of Health Service Management, Anhui Medical University, China
| | - Qian Hong
- School of Health Service Management, Anhui Medical University, China
| | - Hongbo Zhang
- School of Public Health, Anhui Medical University, China
| | - Jing Chai
- School of Health Service Management, Anhui Medical University, China
| | - Gregory Szekeres
- Center for World Health, University of California Los Angeles, USA
| | - Jerome Galea
- Center for World Health, University of California Los Angeles, USA
| | - Thomas J Coates
- Center for World Health, University of California Los Angeles, USA.
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