Between individual agency and structure in HIV prevention: understanding the middle ground of social practice

What can PrEP do for female sex workers? Unpacking the "effectosphere" of biomedical HIV prevention in Dar es Salaam

Pre-exposure prophylaxis (PrEP) is a drug with the power to prevent HIV transmission. This study delved into the broader implications of PrEP use among female sex workers in Dar es Salaam, Tanzania, a group disproportionately affected by HIV and socio-structural challenges. Through 46 in-depth interviews with 40 women who were either former or current PrEP users or intended to start PrEP between January 2021 and February 2022, we sought to explore the nuanced effects of PrEP. Inspired by Whyte et al. and "Social Life of Medicines", we asked what PrEP could do in the lives of female sex workers and analyzed the data using reflexive thematic analysis and an interpretative phenomenological approach. We found that PrEP had multiple and diverse effects in many domains of women's lives and refer to these collectively as the "effectosphere" of PrEP. The study identifies four key themes that jointly describe this effectosphere: (1) PrEP could promote human flourishing and empowerment by facilitating a feeling of freedom and confidence which could promote health, social relations, and economic and work opportunities, (2) PrEP could inflict harm (and fears of such harms), partially reflecting medical mistrust rooted in an understanding that sex workers were undesired in society, (3) PrEP could expose sensitive information about its users that could lead to stigma, arguments and needs for elaborate explanations, and (4) PrEP could medicalize daily life, evidenced through daily pill taking, clinical appointments, side-effects, becoming reliant on the medication, and the challenges of integrating PrEP use with other life priorities. We argue that investigating the full effectosphere of any medicine in particular geographic and sociocultural contexts can lead to a better understanding of its use and non-use, highlighting that engaging with medication extends beyond just "taking a pill."

Developing critical HIV health literacy: insights from interviews with priority migrant communities in Queensland, Australia

In Australia, surveillance data establish that there are higher rates of late HIV diagnoses among heterosexual migrants from Sub-Saharan Africa and new HIV diagnoses among gay and bisexual men (GBM) from Southeast and Northeast Asia and Latin America. Together, these groups are identified as priority migrant communities in current efforts to eliminate HIV transmissions. HIV health literacy is recognised as a key means of improving access to services and health outcomes. This qualitative paper explores critical HIV health literacy among priority migrant communities in Queensland, Australia. To foreground community voices, peer researchers from priority migrant communities participated in the project design, data collection and analysis, with 20 interviews completed. The findings demonstrate how participants' engagement with HIV health information and services is highly relational and situated within the framework of sexual health and wellbeing. Participants strategically selected where to seek information and who they trusted to help them appraise this information. They further demonstrated reflective capacities in identifying the contextual barriers that inhibit the development of their HIV health literacy. The findings highlight the need for HIV health promotion strategies that embrace a sex positive approach, promote cultural change, and involve collaboration with general practitioners (GPs).

Perceived Social Stigma of Cutaneous Leishmaniasis in Hubuna, Saudi Arabia

Background

Cutaneous Leishmaniasis (CL) is a vector-borne skin infection that remains prevalent in regions with poor socioeconomic conditions. Stigmatization occurs when individuals with physical or psychological disorders interact with societal stereotypes. The aim of this study was to explore the perceived social stigma surrounding CL among people residing in Hubuna, Saudi Arabia.

Methods

This cross-sectional community-based survey recruited 618 individuals aged 18 years and above using the snowball sampling technique to reach hidden cases within the target population. Data was collected using a self-administered questionnaire and the Explanatory Model Interview Catalogue for Perceived Social Stigma (EMIC-SS-12) was used to assess the level of perceived social stigma. It includes questions on demographic variables, behaviors, and experiences. The analysis was performed using SPSS.

Results

The study included 618 participants, the majority of whom were women and girls (54.2%), with a mean age of 28 ± 12.7 years. The median score for perceived social stigma was 26.0. Only 2.1% (n = 13) of participants had the highest EMIC-SS-12 score of 36, while 7.6% (n = 47) scored zero. The mean score for overall perceived social stigma was 1.89 ± 0.91, while the mean score for experienced stigma was 1.99 ± 1.02. Univariate analysis showed that sex, employment, location of lesions, and number of lesions were insignificantly associated with stigmatization (P-value < 0.05), because these associations were uncertain because the CI includes or very close to 1.

Conclusion

The study reveals insights into stigmatization associated with CL in the Habuna area of Saudi Arabia. It found that the median of perceived social stigma was 26. Factors such as sex, employment status, and location of the lesion are uncertainly associated with stigma. It is crucial to explore negative behaviors and perceptions and develop suitable health education programs.

Influences on decision-making about disclosure of HIV status by adolescents and young adults living with HIV in KwaZulu-Natal, South Africa

Background: Adolescents and young adults living with HIV (AYA) are faced with the challenge of living with a life-long chronic condition. We investigated the influences on the decisions by AYA to disclose their HIV status to family, intimate partners and friends.Methods: Twenty AYA aged between 15 and 24 years were purposely selected through local community-based organisations in eThekwini municipality and uMkhanyakude district in KwaZulu-Natal Province, South Africa. Virtual in-depth interviews were conducted between September 2020 to October 2021 using a topic guide focusing on HIV-status disclosure and the impact of stigma on decision-making capacity. An iterative thematic process was used for analysis.Results: Findings revealed the challenges that AYA experience for disclosure because of stigma and how this impacts their decision-making capacity. Family and friends influenced AYA in processing their discovery of their HIV status offering support needed to manage living with HIV. However, for some AYA disclosing to relatives, friends and intimate partners was difficult because of fears of rejection and recrimination. The act of disclosure was influenced by both internalised and external stigma and the type of relationships and interactions that AYA had with relatives, friends and caregivers.Conclusions: The decision to disclose is challenging for AYA because of the fear of rejection, along with internal and external stigma. The provision of support, whether from family or peers, is important. Enhancing the decision-making capacity of AYA is essential for developing their self-esteem as well as supporting future healthcare choices.

The effect of pre-exposure prophylaxis (PrEP) on negotiating casual sex between gay men: disclosure, assumptions, and communication

BACKGROUND

The disclosure of HIV status and pre-exposure prophylaxis (PrEP) use can be important in the negotiation of safe sex. With the rapid uptake of PrEP in Australia, norms and expectations about discussion and disclosure may have changed.

METHODS

We explored the disclosure of PrEP use, HIV status and communication with sex partners by HIV-negative gay men in Sydney, Australia. We conducted semi-structured interviews from October 2017 to May 2018 and analysed data using a codebook thematic analysis approach.

RESULTS

Participants had a variety of expectations of what they should tell their partners and what they expected in return. For some participants, PrEP had negated the need for any discussion about HIV. Many participants assumed their partners would find information about their HIV status or PrEP use on their online profiles or that partners would ask, if necessary.

CONCLUSIONS

Building a stronger, shared understanding among gay men that disclosure and discussion no longer automatically occur before sexual encounters may be useful.

'Why aren't you on PrEP? You're a gay man': reification of HIV 'risk' influences perception and behaviour of young sexual minority men and medical providers

Public health models and medical interventions have often failed to consider the impact of reductionist HIV 'risk' discourse on how sexual minority men interpret, enact and embody biomedical knowledge in the context of sexual encounters. The aim of this study was to use an anthropological lens to examine sexual minority men's perception of HIV risk and experience within the medical system in order to examine the influence of risk discourse on their health, behaviour and social norms. In-depth interviews (n = 43) were conducted with a racially, ethnically and socioeconomically diverse sample of young sexual minority men and explored HIV-related beliefs and experiences, as well as their interactions with healthcare providers. Findings suggest that the stigmatisation of behaviours associated with HIV appears to be shaped by three key forces: healthcare provider perceptions of sexual minority men as inherently 'risky', community slut-shaming, and perceptions of risk related to anal sex positioning. Stigmatising notions of risk appear to be embodied through sexual health practices and identities vis-à-vis preferred anal sex positions and appear to influence condom use and PrEP initiation.

Migrants in Swedish sexual and reproductive health and rights related policies: a critical discourse analysis

BACKGROUND

Previous research has shown that migrants in Sweden are disadvantaged in terms of sexual and reproductive health and rights (SRHR). SRHR policies might play a crucial role in shaping migrants' SRHR outcomes. The purpose of the study was to critically examine: a) how migrants were represented in the discourses embedded within Swedish SRHR-related policies, and b) how migrants' SRHR-related issues were framed and addressed within these discourses.

METHODS

Critical discourse analysis (CDA) was used to analyze a total of 54 policy documents. Following Jäger's approach to CDA, discourse strands and entanglements between different discourse strands were examined.

RESULTS

Our findings consisted of three discourse strands: 1) "Emphasizing vulnerability", 2) "Constructing otherness", and 3) "Prioritizing the structural level or the individual level?". Migrants' representation in Swedish SRHR-related policies is often associated with the concept of vulnerability, a concept that can hold negative connotations such as reinforcing social control, stigma, and disempowerment. Alongside the discourse of vulnerability, the discourse of otherness appears when framing migrants' SRHR in relation to what is defined as honor-related violence and oppression. Furthermore, migrant SRHR issues are occasionally conceptualized as structural issues, as suggested by the human rights-based approach embraced by Swedish SRHR-related policies. Relevant structural factors, namely migration laws and regulations, are omitted when addressing, for example, human trafficking and HIV/AIDS.

CONCLUSIONS

We conclude that the dominant discourses favor depictions of migrants as vulnerable and as the Other. Moreover, despite the prevailing human rights-based discourse, structural factors are not always considered when framing and addressing migrants' SRHR issues. This paper calls for a critical analysis of the concept of vulnerability in relation to migrants' SRHR. It also highlights the importance of avoiding othering and paying attention to the structural factors when addressing migrants' SRHR.

Towards a context-specific understanding of masculinities in Eswatini within voluntary medical male circumcision programming

Compelling evidence from three randomised controlled trials, which showed that voluntary medical male circumcision (VMMC) reduces HIV acquisition from women to men by up to 60%, led to WHO recommending that VMMC be implemented in 14 priority countries. As one of the priority countries, Eswatini aimed to reach 80% VMMC coverage among boys and men aged 10-49 years since programme inception in 2009. By the end of 2019, however, the country had reached a modest 40%. VMMC is intrinsically tied to perceptions of masculinity and male gender identity. Comprehending the role of context-specific masculinity as it relates to VMMC may contribute to our understanding of community attitudes towards VMMC and men's decision-making. Drawing on focus group discussion data, this study aimed to explore the linkage between sexuality, masculinity and health interventions within Eswatini. Using critical discourse analysis, the study identified two discourses: sexuality, masculinity and circumcision, and income, masculinity, and circumcision. In the first discourse, participants constructed discursive linkages between circumcision as an adult and loss of penile sensitivity, decreased libido and sexual performance, and adverse events. The second discourse, income, masculinity, and circumcision located circumcision within the social and material realities faced by Swazi men, gender norms and provision within family structures.

Co-occurring Threats to Agency Among Female Sex Workers in Baltimore, Maryland

Driven largely by the unequal distribution of power, female sex workers (FSW) globally bear a disproportionately high burden of HIV, sexually transmitted infections, and interpersonal violence. Prior literature has identified a number of multi-level factors that may serve to constrain FSWs' agency, or their ability to define and take action to realize goals. Among these are work-based violence and substance use, which are potentiated by the criminalization of sex work and structural vulnerability. Quantitative research related to U.S.-based FSWs' own sense of agency, as well as the barriers that may impede it, is sparse. We sought to identify patterns of various threats to agency and explore to what extent they were associated with perceived agency among a cohort of 381 FSW in Baltimore, Maryland, United States, using latent class analysis. Latent class indictors were past-six-month experience of client-perpetrated sexual violence, client-perpetrated physical violence, homelessness, food insecurity, arrest, daily crack-cocaine use, and daily heroin use. Perceived agency was measured using the short form of the Pearlin Mastery Scale. We identified three typologies of threatened agency among women in our sample: a "threatened by structural factors, drug use, and violence" class, a "threatened by structural factors and drug use" class, and a "less threatened" class. Mean perceived agency score was significantly lower for the class characterized by client-perpetrated violence than for either of the other classes. This suggests violence, in the context of deeper, structural power imbalances embedded in hunger, homelessness, and drug use, may dramatically reduce one's sense of agency and operate as a critical barrier to empowerment. Our study adds important insights to the broader FSW community empowerment literature and supports the need for interventions to bolster both individual and collective agency among U.S.-based FSW, including interventions to prevent sex work-related violence.

Getting to zero HIV/AIDS in sub-Saharan Africa: Understanding perceptions of locals using the social determinants of health framework

This study explored a community perception of the facilitators and inhibitors of Getting to Zero (GTZ) in rural Zambia, sub-Saharan Africa. Data were collected in 2017. We use the Social Determinants of Health framework to guide organisation of key themes emerging from semistructured, focus group interviews with community members (N = 52). Data were analysed through an iterative descriptive/thematic approach which allowed for the highlighting of key themes. Emerging themes point to the significance of (a) individual, (b) sociocultural, (c) environmental and (d) economic factors, for example, treatment adherence, gender norms, food security and access to health care as important in GTZ. Implications for policy, practise and scholarship are suggested.

Community Mobilization Challenging Gender Power Imbalances: Women Sex Workers' Capacity to Engage in Health-Enhancing Practices in Southern India

Research on women sex workers' condom use with non-paying intimate partners suggests social norms of gender power in these relationships constrain women's health-enhancing sexual practice. Theorizing gender relations and sexual practice as structural informs our analysis of elements of community mobilization interventions (CMI) that link to sex workers' capacity to engage consistently in health-enhancing practices, in this case, condom use. We use data from a survey of women (who exchanged sex for money in the preceding 12 months) conducted in the context of an HIV-prevention intervention in southern India. Results of multinomial logistic regression indicate: higher odds of health-enhancing sexual practice with intimate partners and paying clients among women sex workers expressing collective efficacy; lower odds of health-diminishing sexual practice with clients among women sex workers empowered through peer interactions; lower odds of health-diminishing sexual practice with clients and lower odds of health-enhancing sexual practice with partners among women sex worker living in households structured by normative gender power relations. We suggest future research on how CMI promoting health-enabling social environments with women in sex work contribute to their capacity to engage in health-enhancing practices.

Sexual risk-taking among homeless young people in Pakistan

Homeless young people who engage in sex work are at increased risk of HIV and other sexually transmitted infections like chlamydia, gonorrhoea, syphilis and herpes. Semi-structured interviews were conducted with 29 homeless young people between the ages of 16 and 25 years from Rawalpindi, Pakistan, to explore how sexual practices were mediated through social and contextual conditions. Participants engaged in sex for a range of reported reasons, most commonly to generate income, but also to build intimacy and to establish intimate partnerships which could bring physical protection and social and emotional support. Although participants were aware of the sexual health risks attached to condomless sex, they engaged in it due to the social obligations of intimate partnerships, financial considerations and to better manage potentially violent situations. Instead of condoms, participants used alternate methods like withdrawal, oral sex, post-sex douching and specific sexual positions. These were not always useful, and some methods might have inadvertently increased their risk of HIV. The study findings suggest that an integrated health promotion approach that goes beyond the health sector and a singular emphasis on risk awareness may help reduce young people's risk of homelessness and sexual health risks.

Sexual subjectivity among young female students at a university in Zimbabwe

Perched precariously within the socio-economic hierarchy of the Zimbabwean nation, young female students in tertiary institutions adopt different strategies to survive and sustain themselves as they continue with their studies. This article considers how young women constitute sexual subjectivity through an analysis of primary narratives circulating around specific sexual practices and decisions. Focus is placed on how young women's sexual choices are influenced and enveloped within unequal gender relations, which afford them little space to negotiate the nature of sexual relationships.

Sexual rights and sexual pleasure: Sustainable Development Goals and the omitted dimensions of the leave no one behind sexual health agenda

This commentary explores the missing discourse of sexual rights and sexual pleasure in the Sustainable Development Goals (SDG) that purport to leave no one behind. The SDG propose a welcome focus on sexual health and human rights for all, expanding beyond the Millennium Development Goals. While promising in many ways for advancing global sexual and reproductive health, and reproductive rights, the omission of sexual rights is troubling. So too is the erasure of lesbian, gay, bisexual, transgender and queer (LGBTQ) persons, and sex workers, from the SDG discussions of social inequities. Illustrative examples are provided to demonstrate how a sexual rights focus could advance SDG 3 focused on healthy lives and well-being for all. First, sexual rights are presented as integral to realizing Target 3.3's focus on ending the HIV pandemic among LGBTQ persons and sex workers (and LGBTQ sex workers). Second, sexual pleasure is introduced as an integral component of sexual health and sexual rights that could facilitate the realization of Target 3.7's aim to provide universal access to sexual and reproductive health information and education. To truly leave no one behind and realize sexual health for all, the SDG need to begin from a foundation of sexual rights.

Reproductive health among Venezuelan migrant women at the north western border of Brazil: A qualitative study

BACKGROUND

Venezuela has been immersed in an economic and social crisis with a high number of migrant people. An important proportion of Venezuelan migrants have crossed the north western border Brazil-Venezuela were the United Nations High Commissioner for Refugees (UNHCR) has established 13 shelters. Our objectives were to know perspectives and views of Venezuelan migrant women hosted at UNHCR shelters on some SRH issues.

METHODS

We conducted a qualitative study between November 2019 and February 2020 with 12 focus group discussions (FGDs), with 111 Venezuelan migrant women of reproductive age (18-49 years old). FGDs were performed in a closed space that guaranteed confidentiality, were recorded, verbatim transcribed and data were analised for thematic manifest content.

FINDINGS

The themes identified were perspectives on: i) health care for pregnant and postnatal women, ii) access to modern contraceptive methods, and iii) HIV and sexually transmitted diseases (STDs). Despite the general satisfaction with obstetric care, women noted few challenges pertaining to their experiences during first entry to antenatal care, labour, delivery and postnatal care. They were in agreement that access to long-acting reversible contraceptives was difficult, mainly to the copper-intrauterine device (IUD); which when available it was erratic. Hormonal-IUD and implants were almost inexistent. This was of major concern to the women, as it prevented them from the ability to plan their reproductive lives. Although knowledge on STDs/HIV prevention and transmission was adequate; the predominance of traditional gender imbalance in the relations was observed and these attitudes have been discussed as a barrier for migrant women to protect themselves against HIV/STD infection.

CONCLUSION

These migrant women needed help to understand the language and functioning of the healthcare system, to overcome barriers and challenges while seeking access to SRH care. They faced significant gender vulnerability that needs to be addressed within their new life. Our findings could be useful for health authorities and international organisations to start actions to improve SRH and mitigate suffering.

A scoping review of the integration of empowerment-based perspectives in quantitative intersectional stigma research

The genesis of the concept of intersectionality was a call to dismantle interlocking systems of oppression - racial, sexual, heterosexual, and class-based - in order to realise liberation of Black women and other women of colour. Intersectionality holds the radical potential to amplify collective efficacy, community solidarity, and liberation. The extension of intersectionality into stigma research has resulted in an increased focus on intersectional stigma in quantitative research. This raises questions regarding how the radical and liberatory potential of intersectionality is applied in stigma research. Specifically, empowerment-based perspectives may be overlooked in quantitative intersectional stigma research. We conducted a scoping review to document if and how empowerment-based perspectives were included in intersectional stigma quantitative studies. We identified and included 32 studies in this review that examined varied stigmas, most commonly related to race, gender, HIV and sexual orientation. In total 13/32 (40.6%) of these studies reported on empowerment-based factors; most of these examined social support and/or resilience. Taken together, findings suggest that the quantitative intersectional stigma research field would benefit from expansion of concepts studied to include activism and solidarity, as well as methodological approaches to identify the protective roles of empowerment-based factors to inform health and social justice-related programmes and policy.

The contested global politics of pleasure and danger: Sexuality, gender, health and human rights

This special issue of Global Public Health brings together papers examining how sexuality, gender, health and human rights have become increasing visible and highly contested within global health. The papers included here question and explore the often contradictory processes through which global equity-seeking populations negotiate pleasure and danger across multiple arenas (including HIV and AIDS, LGBTQ+ health and rights, intersex rights, sex worker rights, realities of refugee and displaced persons, and gender-based violence) and in diverse geographic contexts (Afghanistan, Bangladesh, Canada, Ghana, Haiti, Kenya, Mauritania, Nigeria, Peru, Rwanda, and the USA). These papers examine emerging questions about the gaps and limits in current legal structures that do not legitimize sexual rights as fundamental human rights, the role of agency (and of bounded agency) needed to navigate constrained contexts, ways in which community-based solidarity efforts shape access to sexual rights, and how sexual pleasure and consent are experienced and negotiated in rights-constrained contexts. The interdisciplinary authors included in this collection showcase how the ranging definitions of sexual rights, their enactment, and expressions of pleasure and danger are inextricably entangled with local contexts and cultural systems that underpin not only people's lived experience but simultaneously become central topics for global health research, policy and practice.

Ambivalence and the biopolitics of HIV pre-exposure prophylaxis (PrEP) implementation

Ambivalence, the vacillation between conflicting feelings and thoughts, is a key characteristic of scientific knowledge production and emergent biomedical technology. Drawing from sociological theory on ambivalence, we have examined three areas of debate surrounding the early implementation of HIV pre-exposure prophylaxis, or PrEP, for gay, bisexual, queer, and other men who have sex with men in Canada, including epistemology and praxis, clinical and epidemiological implications, and sexual politics. These debates are not focused on the science or efficacy of PrEP to prevent HIV, but rather represent contradictory feelings and opinions about the biopolitics of PrEP and health inequities. Emphasizing how scientists and health practitioners may feel conflicted about the biopolitics of novel biomedical technologies opens up opportunities to consider how a scientific field is or is not adequately advancing issues of equity. Scientists ignoring their ambivalence over the state of their research field may be deemed necessary to achieve a specific implementation goal, but this emotion management work can lead to alienation. We argue that recognizing the emotional dimensions of doing HIV research is not a distraction from "real" science, but can instead be a reflexive site to develop pertinent lines of inquiry better suited at addressing health inequities.

Illuminating the empowerment journey of caregivers of children with disabilities: Understanding lessons learnt from Ghana

BACKGROUND

Empowerment is an increasingly popular goal, considered core to a transformative agenda for children with disabilities and their families. However, it can still be a poorly understood concept in practice.

OBJECTIVE

This article is an empirical analysis of the 'empowerment journeys' of caregivers participating in a community-based training programme in Ghana.

METHOD

In-depth interviews were conducted with 18 caregivers at three time points over 14 months. Thematic analysis was conducted on the full data set, with three representative case studies selected for more detailed analysis to illustrate the dynamism of time and context in shaping the empowerment journey.

RESULTS

Our findings illuminate the complexity and non-linearity of the caregiver empowerment journey. There were important gains in individual dimensions of power and the nascent emergence of collective power, through improved knowledge and valuable peer support from group membership. However, further gains were impeded by their limited influence over wider economic and sociopolitical structural issues that perpetuated their experiences of poverty, stigma and the gendered nature of caregiving. The support group facilitator often played a valuable brokering role to help traverse individual agency and structural issues.

CONCLUSION

A richer and more nuanced understanding of caregiver empowerment in the community and family context can inform the wider discourse on disability. Guidelines on working with people with disabilities, and the role of empowerment, should not neglect the pivotal role of caregivers. There are important lessons to be learnt if we want to improve family-centred interventions and transform the lives of children with disabilities.

HIV stigma by association among Australian gay and bisexual men

OBJECTIVE

The negative effects of HIV stigma may extend beyond those who are HIV-positive, to people who are perceived to be at risk of HIV. This article examines HIV stigma by association among Australian gay and bisexual men (GBM).

DESIGN

Cross-sectional, online survey of 1280 Australian gay and bisexual men. This article focuses on HIV stigma from within a larger study that investigated stigma related to sexual identity.

METHODS

Bivariate and multivariable comparisons were made between men who experienced HIV stigma by association and those who did not. A serial mediation model was tested to investigate relationships between GBM community attachment, sexual identity stigma, HIV testing frequency, HIV stigma by association, psychological distress, and rejection of sex partners.

RESULTS

Results found that 5% of participants were HIV-positive, yet over 70% reported that they had been stigmatized by others for their perceived risk of acquiring HIV. Multivariable analysis indicated that HIV stigma by association was associated with more frequent HIV testing, greater GBM community attachment, experiencing stigma related to sexual identity and psychological distress. Our results suggest flow-on effects of HIV stigma by association, such as being more likely to reject other GBM on the basis of their HIV status or not testing for HIV.

CONCLUSION

Our results underscore the notion that HIV stigma can have broader, negative effects on HIV-affected populations. There is a need to address HIV stigma within GBM communities and society more broadly in order to encourage HIV testing and prevention among GBM.

Premarital relationships and condom use among young people in Suva, Fiji

Background Young people in Fiji experience high rates of sexually transmissible infections and early pregnancy. Despite being identified as a key priority group in national strategies, little is known about use of condoms among young people in premarital relationships. This study aimed to enhance understandings of premarital sex and condom use practices among young people in Fiji.

METHODS

Focus group discussions with 33 young women and men aged 18-29 years and 17 interviews with young women aged 18-26 years in an urban setting in Fiji were conducted. Inductive thematic analysis examined condom use practices.

RESULTS

Participants described a range of contextual influences inhibiting or enabling condom use. Factors inhibiting condom use included sociocultural expectations regarding premarital abstinence; young people's engagement in hidden sexual relationships; limited intergenerational dialogue about sexual health issues; judgmental attitude of staff at condom access points; male dominance of condom use preferences; and belief condoms disrupt intimacy, reduce sexual pleasure and infer a lack of trust. Factors that enhanced condom use included accessing condoms through discreet methods; adult beliefs that supported safe sex practices; and refusing to have sex without a condom.

CONCLUSION

Findings broaden understandings of young people's condom use practices in Suva, Fiji. The findings illustrate the need for culturally appropriate youth-centred sexual and reproductive health (SRH) programs and services. Specific strategies that might enhance young people's condom use include community- and youth-led responses; peer condom distribution; provision of condom dispensers in community settings; scaling up of youth-friendly SRH services; and the delivery of comprehensive sexuality and relationships education.

'If the results are negative, they motivate us'. Experiences of early infant diagnosis of HIV and engagement in Option B

Few studies have explored the relationship between early infant diagnosis (EID) of HIV and mothers' engagement in care under Option B+. We conducted in-depth interviews with 20 women who initiated antiretroviral therapy (ART) under Option B+ in rural South Africa to explore the interactions between EID and maternal care engagement. Drawing on practice theory, we identified themes relating to Option B+ care engagement and EID. Women's practice of engagement with HIV care shaped their decision-making around EID. Mothers who disengaged from care during pregnancy were less inclined to utilise EID as they lacked information about its availability and benefits. For some mothers, tensions between wanting to breastfeed and perceptions that it could facilitate transmission led to repeated utilisation of EID as reassurance that the child remained negative. Some mothers used their child's negative result as a proxy for their status, subsequently disengaging from care. For some participants, an HIV diagnosis of their infant and the subsequent double burden of treatment visits for themselves and their infant, contributed to their disengagement. Women's care-seeking practices for themselves and their infants work in a symbiotic ecosystem and should be viewed interdependently to tailor interventions to improve EID uptake and Option B+ care engagement.

Religion, faith, and spirituality influences on HIV prevention activities: A scoping review

INTRODUCTION

Strategies to increase uptake of next-generation biomedical prevention technologies (e.g., long-acting injectable pre-exposure prophylaxis (PrEP)) can benefit from understanding associations between religion, faith, and spirituality (RFS) and current primary HIV prevention activities (e.g., condoms and oral PrEP) along with the mechanisms which underlie these associations.

METHODS

We searched PubMed, Embase, Academic Search Premier, Web of Science, and Sociological Abstracts for empirical articles that investigated and quantified relationships between RFS and primary HIV prevention activities outlined by the United States (U.S.) Department of Health and Human Services: condom use, HIV and STI testing, number of sexual partners, injection drug use treatment, medical male circumcision, and PrEP. We included articles in English language published between 2000 and 2020. We coded and analyzed studies based on a conceptual model. We then developed summary tables to describe the relation between RFS variables and the HIV prevention activities and any underlying mechanisms. We used CiteNetExplorer to analyze citation patterns.

RESULTS

We identified 2881 unique manuscripts and reviewed 29. The earliest eligible study was published in 2001, 41% were from Africa and 48% were from the U.S. RFS measures included attendance at religious services or interventions in religious settings; religious and/or spirituality scales, and measures that represent the influence of religion on behaviors. Twelve studies included multiple RFS measures. Twenty-one studies examined RFS in association with condom use, ten with HIV testing, nine with number of sexual partners, and one with PrEP. Fourteen (48%) documented a positive or protective association between all RFS factors examined and one or more HIV prevention activities. Among studies reporting a positive association, beliefs and values related to sexuality was the most frequently observed mechanism. Among studies reporting negative associations, behavioral norms, social influence, and beliefs and values related to sexuality were observed equally. Studies infrequently cited each other.

CONCLUSION

More than half of the studies in this review reported a positive/protective association between RFS and HIV prevention activities, with condom use being the most frequently studied, and all having some protective association with HIV testing behaviors. Beliefs and values related to sexuality are possible mechanisms that could underpin RFS-related HIV prevention interventions. More studies are needed on PrEP and spirituality/subjective religiosity.

Strategies to support HIV literacy in the roll-out of pre-exposure prophylaxis in Scotland: findings from qualitative research with clinical and community practitioners

OBJECTIVES

Limited understanding of pre-exposure prophylaxis (PrEP), coupled with negative public discourse, are significant barriers to its introduction. What works to support PrEP awareness and broader HIV literacy among diverse communities in the context of biomedical HIV prevention remains unclear. This article considers how PrEP can be translated across diverse communities and what the HIV literacy challenges might be in the current context of PrEP provision.

SETTING

We developed an HIV literacy informed community tool to support the roll-out of PrEP in Scotland. We undertook qualitative research with practitioners in urban and rural settings across nine Scottish health boards.

PRIMARY OUTCOME MEASURE

To examine HIV literacy challenges in the context of PrEP provision.

PARTICIPANTS

Interviews and focus groups with community (n=19) and clinical (n=13) practitioners working with gay and bisexual men and African communities were undertaken between March and October 2017 concerning PrEP support, stigma and HIV literacy.

RESULTS

HIV literacy in the context of PrEP needs to consider more than the provision of individually targeted information. Practitioners identified and responded to stratified communities and social norms of knowledge, which influenced messaging, support and informed how practitioners enabled PrEP engagement and dialogue. Social barriers in HIV literacy, including structural stigmas relating to HIV and homophobia, shaped practitioner concerns and support for community members' willingness to engage with PrEP.

CONCLUSION

Critical HIV literacy in the age of PrEP is a complex social practice. Attention needs to be paid to how information is provided and facilitates engagement, rather than simply what information is given.By exploring practitioner use of the Know about PrEP tool, we have shown how consideration of the patterns of access to services and information, the delivery of and support for engagement with PrEP information and the wider strategies employed to negotiate ongoing structural social barriers can support more equitable and diverse PrEP community conversations.

Factoring civil society actors into health policy processes in low- and middle-income countries: a review of research articles, 2007-16

Civil society actors have substantially increased their participation in global and national health policymaking processes since the 1970s. Civil society roles in shaping such significant global health milestones as the Doha Declaration on Intellectual Property Rights, the Framework Convention on Tobacco Control and the recently adopted United Nations Sustainable Development Goals are well documented, but knowledge of civil society actor influence on health policy processes in low- and middle-income countries remains fragmented. This study analyses 24 peer-reviewed research articles published between 2007 and 2016 to identify factors affecting civil society influence in the pre-implementation stages of the policy process. The articles reviewed span 13 health issues and more than 50 countries in four regions of the world. This body of work focuses on civil society as represented by formal groups, primarily domestic and to some extent international non-governmental organizations, but also social movements, professional associations and faith-based organizations, among others. The studies document several actor-centred and contextual factors that affect civil society actor power, commonly across stages of the policy process. Crucially, civil society actors were challenged to impact the process in countries that lacked participative norms and governing structures. When repressive conditions existed, regime changes and donors sometimes helped to open doors to participation. The power of civil society actors was enhanced when they joined strong epistemic networks and broader coalitions of stakeholders, were resourced, and framed issues in ways that resonated with national policies and political priorities. The synthesis offers guidance to practitioners on factors to consider in strategy development and points to several issues for further investigation by health policy analysis scholars, including the implications of issue (non)adoption by civil society actors and contestation dynamics among those with differing perspectives.

Facilitating engagement with PrEP and other HIV prevention technologies through practice-based combination prevention

INTRODUCTION

Recent years have witnessed a rapid expansion of efficacious biomedical HIV prevention technologies. Promising as they may be, they are largely delivered through standard, clinic-based models, often in isolation from structural and behavioural interventions. This contributes to varied, and often poor, uptake and adherence. There is a critical need to develop analytical tools that can advance our understandings and responses to the combination of interventions that affect engagement with HIV prevention technologies. This commentary makes a call for practice-based combination HIV prevention analysis and action, and presents a tool to facilitate this challenging but crucial endeavour.

DISCUSSION

Models and frameworks for combination HIV prevention already exist, but the process of identifying precisely what multi-level factors that need to be considered as part of a combination of HIV interventions for particular populations and settings is unclear. Drawing on contemporary social practice theory, this paper develops a "table of questioning" to help interrogate the chain and combination of multi-level factors that shape engagement with HIV prevention technologies. The tool also supports an examination of other shared social practices, which at different levels, and in different ways, affect engagement with HIV prevention technologies. It facilitates an analysis of the range of factors and social practices that need to be synchronized in order to establish engagement with HIV prevention technologies as a possible and desirable thing to do. Such analysis can help uncover local hitherto un-identified issues and provide a platform for novel synergistic approaches for action that are not otherwise obvious. The tool is discussed in relation to PrEP among adolescent girls and young women in sub-Saharan Africa.

CONCLUSIONS

By treating engagement with HIV prevention technologies as a social practice and site of analysis and public health action, HIV prevention service planners and evaluators can identify and respond to the combination of factors and social practices that interact to form the context that supports or prohibits engagement with HIV prevention technologies for particular populations.

Challenges facing HIV treatment as prevention in Brazil: an analysis drawing on literature on testing

According to current global AIDS guidelines, HIV testing is key to the success of the 'treatment as prevention' (TasP) strategy and the control of AIDS. In view of Brazil's commitment to these guidelines, this article characterizes the principles and justifications underpinning TasP and discusses implementation challenges. The analysis draws on a systematic review of the literature (2005 to 2015) on recruitment and testing strategies for men who have sex with men. This approach was adopted based on the assumption that current knowledge on HIV testing can offer valuable insights into the foundations of global AIDS policies and their uptake in local contexts. Based on the analysis of the 65 articles selected, we suggest that TasP represents a shift in the AIDS prevention paradigm. There is an overlap between prevention and care and the new approach places major emphasis on biomedical and psychological knowledge. The TasP approach fails to address the factors associated with HIV vulnerability and the stigma surrounding AIDS and undermines the participation of activists and PLWHA as autonomous producers of preventive of preventive practices. We argue that, to ensure the effective implementation of TasP in Brazil, it is necessary to discuss issues such as the protection of human rights and the structural problems facing Brazil's public health system.

Simbayi L, Barré I, Dovidio JF. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas

Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally. In order to halt the stigmatization process and mitigate the harmful consequences of health-related stigma (i.e. stigma associated with health conditions), it is critical to have an explicit theoretical framework to guide intervention development, measurement, research, and policy. Existing stigma frameworks typically focus on one health condition in isolation and often concentrate on the psychological pathways occurring among individuals. This tendency has encouraged a siloed approach to research on health-related stigmas, focusing on individuals, impeding both comparisons across stigmatized conditions and research on innovations to reduce health-related stigma and improve health outcomes. We propose the Health Stigma and Discrimination Framework, which is a global, crosscutting framework based on theory, research, and practice, and demonstrate its application to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV, and obesity/overweight. We also discuss how stigma related to race, gender, sexual orientation, class, and occupation intersects with health-related stigmas, and examine how the framework can be used to enhance research, programming, and policy efforts. Research and interventions inspired by a common framework will enable the field to identify similarities and differences in stigma processes across diseases and will amplify our collective ability to respond effectively and at-scale to a major driver of poor health outcomes globally.

Rebooting resilience: shifts toward dynamic, multi-level, and technology-based approaches for people living with HIV

Resilience research has often been characterized by a static conceptualization of resilience that focuses on individual-level factors that help people living with HIV (PLHIV) adapt to HIV-related challenges and overcome other life adversities. Early conceptualizations often depicted resilience as a static, stable construct, with limited attention paid to the social context and broader systems that may foster or discourage resilient adaptation across time and place. This special issue seeks to challenge these conventional views by highlighting innovative HIV resilience research across the globe. Far from ignoring socio-cultural contexts, studies presented in this issue directly address systemic stigma and discrimination against PLHIV, as well as sexual and gender minority individuals, and identify unique opportunities to promote resilience through building strong "villages" (i.e., social networks), reducing structural inequities, and enhancing HIV treatment and care systems. In addition, papers included in this issue address the promise and challenges of utilizing mobile Heath (mHealth) technology to build resilience for PLHIV through improving psychosocial and clinical outcomes.

A support programme for caregivers of children with disabilities in Ghana: Understanding the impact on the wellbeing of caregivers

BACKGROUND

Four fifths of the estimated 150 million children with disability in the world live in resource poor settings where the role of the family is crucial in ensuring that these children survive and thrive. Despite their critical role, evidence is lacking on how to provide optimal support to these families. This study explores the impact of a participatory training programme for caregivers delivered through a local support group, with a focus on understanding caregiver wellbeing.

METHODS

A qualitative longitudinal study was conducted to investigate the impact of a training programme, "getting to know cerebral palsy," with caregivers on their wellbeing. Eighteen caregivers, from four districts, were interviewed up to three times over 14 months, to assess impact and the reasons for any changes.

RESULTS

Low levels of knowledge, high levels of stigma, physical and emotional exhaustion, and often difficult family relationships with social exclusion of the child and caregiver were common themes at the outset. Caregivers struggled to combine their caring and economic activities. This was exacerbated by the common absence of the father. Two months after completion of the training, their reported wellbeing had improved. The reasons for this were an improved understanding about their child's condition, positive attitudinal change towards their child, feelings of hope, and through the group support, a profound realisation that they are "not on their own." While relationships within the family remained complex in many cases, the support group offered an important and alternative social support network.

CONCLUSIONS

This study illustrates the many benefits of a relatively simple caregiver intervention, which has the potential to offer a mechanism to provide sustainable social support for caregivers and children with cerebral palsy. Any future programme needs to also address more structural issues, including stigma and discrimination, and strengthen approaches to family engagement.

'It's just an excuse to slut around': gay and bisexual mens' constructions of HIV pre-exposure prophylaxis (PrEP) as a social problem

Since the 2012 FDA approval of HIV Pre-exposure Prophylaxis (PrEP) as a method to prevent HIV, its uptake among gay and bisexual men has been met with conflict. Drawing on discussions of PrEP from focus groups with gay and bisexual men in New York City (N = 5 groups, n = 32 participants), we sought to make meaning of the moral debate surrounding the implementation of biomedical HIV prevention medications. Grounded in the constructionist perspective on social problems, this case study focuses on the competing claims making activities gay and bisexual men engage in when framing PrEP and PrEP users. As HIV prevention is a communicative endeavour, analysing the micro level social problems work on PrEP provides key insight into the subcultural norms and values that shape sexual health practices and beliefs within gay and bisexual communities.

Education, poverty and "purity" in the context of adolescent girls' secondary school retention and dropout: A qualitative study from Karnataka, southern India

BACKGROUND

Gender-related norms and poverty remain important structural barriers to secondary school attendance among adolescent girls in southern India. We analyse how gender norms interact with family deprivation and dynamics to result in girls dropping out of school; we identify the main facilitators of school retention and changes to gender socialisation.

METHODS

Longitudinal qualitative case studies with 36 girls were nested within a cluster randomized trial to evaluate the Samata intervention targeting adolescent girls in Bagalkote and Vijayapura districts in northern Karnataka. We used two rounds of in-depth interviews, conducted in 2014 at a time when respondents were in 8th standard at the age of 13 to 14 and sixteen months later. We combined thematic and narrative analyses.

RESULTS

Our study found that poverty and socioeconomic realities at the household level strongly affect conformity with discriminatory gender practices such as restricting girls' mobility. The value placed on education by parents clearly differentiates the regular school goers from those frequently absent and others who dropped out. With active encouragement of the girls' educational and career aspirations, parents engendered the girl's agency to communicate openly both at home and at school, allowing subtle changes to gender performance while resisting the pressure of social sanctions. In contrast, where educational aspirations were weak, parents invested more intensely in enforcing correct performance of gender, prioritising her well-being by aiming to secure her future in a good marriage. Among poorer families, girls' domestic duties came at the cost of schooling with concerns about protecting her sexual purity predominating.

CONCLUSIONS

In contexts where a strong gender ideology of virginity before marriage rules, subtle shifts in harmful gender practices are possible. Interventions aiming to improve education need to target the most deprived families, focussing on trust building through open communication.

Contesting restrictive mobility norms among female mentors implementing a sport based programme for young girls in a Mumbai slum

Background

Harmful gender norms are known structural barriers to many public health and development interventions involving adolescent girls. In India, restrictions on girls’ liberty to move freely in public spaces contribute to school dropout and early marriage, and negatively affect girls’ health and wellbeing, from adolescence into adulthood. We report on mechanisms of change among female mentors 18 to 24 years old who contested discriminatory norms while implementing a sports-based programme for adolescent girls in a Mumbai slum.

Methods

We adopted a prospective qualitative research design. Our analysis is based on case studies derived from two rounds of face to face, in -depth interviews with 10 young women recruited to serve as mentors for the project’s young female athletes. We combined both thematic and narrative analysis.

Results

The programme created opportunities for collective action, increasing mentors’ ability to think and relate in a collectivized manner, and challenged the traditional female identity constructed for young women, which centres on domestic duties. The mentors themselves negotiated freedoms both in and outside their homes, which required careful and strategic bargaining. They changed the nature of key day-to-day social interactions with parents and brothers, as well as with neighbours, parents of their groups of athletes and men on the streets. They formed a new reference group for each other in terms of what was possible and acceptable. Demonstrating greater negotiation skills within the family helped win parents’ trust in the mentor’s ability to be safe in public spaces. Parents became active supporters by not giving into social sanctions of neighbours and relatives thus co-producing a new identity for their daughters as respectable young women doing ‘good work’. They effectively side stepped reputational risk with their presence in public spaces becoming de-sexualised.

Conclusions

Mentors contested mobility restrictions by taking risks as a group first, with collective agency an important step towards greater individual agency. This research provides important insights into addressing embedded social norms that perpetuate gender discriminatory practices and the social patterning of health inequalities.

Providers' Perceptions of Couples' HIV Testing and Counseling (CHTC): Perspectives From a U.S. HIV Epicenter

Current epidemiology demonstrate the significance of couple-based HIV transmission among vulnerable U.S. populations and its contribution to health disparity in HIV prevalence. Couples HIV testing and counseling (CHTC) can be used to address couple-based HIV risk in the U.S. Though a globally recognized service, the literature lacks U.S.-based healthcare providers' (HCP) perspectives of CHTC. To address this research gap, a qualitative descriptive design was used to ascertain HCPs' perceptions about CHTC. Semi-structured in-depth interviews were conducted with 22 HCPs who were experienced with engaging patients or clients across the HIV care continuum. Overall, HCPs supported CHTC among different U.S.

POPULATIONS

Content and thematic analysis revealed HCPs perceived CHTC to be an evolution from current HIV testing approaches and a mechanism to screen people who may not otherwise. CHTC was perceived to have biomedical and bio-behavioral merit that warranted consideration for implementation within health service settings and among populations with heightened HIV risk. This strategy was perceived to be a mechanism for introducing PrEP and conception health into one's practice. CHTC also signaled patients reorienting perceptions of personal health as being linked to the health of another individual. Providers recognized that couples have evolved to be increasingly non-heteronormative and thought that CHTC should be offered to all couples. However, participants also noted that HCPs in the U.S. need to be comfortable with promoting sexual health among various populations for implementation of CHTC to be successful.

HIV Testing in Men who have Sex with Men: A Follow-up Review of the Qualitative Literature since 2010

The landscape of HIV testing has changed significantly in recent years following the rise in importance of the 'treatment as prevention' strategy and advancements in new HIV testing and prevention technologies. This review provides a synthesis of qualitative research findings published since 2010 on preferences and practices of men who have sex with men (MSM) surrounding HIV testing in high-income settings. MSM are one of the hardest groups to reach with standard or conventional HIV testing approaches. To develop innovative testing strategies for this particular group, a good understanding of their concerns, barriers and facilitators of accessing HIV testing is needed. This updated review provides valuable information for improving existing programs and designing new testing services for MSM.

Institutional context and VCT practitioner narratives: possibilities and limitations for HIV prevention in Rio de Janeiro, Brazil

BACKGROUND

Voluntary Counseling and Testing (VCT) is an HIV prevention strategy that promotes the principles of confidentiality and informed consent. International research has highlighted VCT counselors' isolation from service planning and the contradictions they negotiate between local values and global testing recommendations. In Brazil, studies have identified many limitations, including counselors' difficulties to implement a vulnerability approach to HIV prevention as recommended in the country's national guidelines. These studies, however, have not considered the particularities of the institutional contexts where counselors work. This research addresses these gaps in the VCT literature by exploring how VCT services are organized and how counselors perceive and perform their practices in the state of Rio de Janeiro, Brazil.

METHODS

This is a case study of VCT services in the state of Rio de Janeiro. The research design included individual structured interviews with seven VCT service coordinators and twenty individual semi-structured interviews with VCT counselors. Participants were sampled according to gender, undergraduate degree and work trajectory to capture a diverse range counselor narratives.

RESULTS

The VCT services were relatively homogenous in terms of functioning and had a similar restricted roll of activities including individual counseling and occasional external prevention activities with groups vulnerable to HIV. All VCT services reported reductions in staff size. Some counselors used dialogical practices to build trust, guarantee confidentiality and adjust their practices in accordance with their clients' values and practices. Others emphasized imperative messages or focused on risk and individual responsibility. Connections between how counselors perceive their practices and the organization of their work environment were observed.

CONCLUSIONS

Due to the importance of counseling as a prevention strategy we recommend rethinking the relationship between counselors' practices and the organization of VCT services. The challenges brought about by the expansion of "test and treat" programs globally and other social and symbolic aspects of the HIV epidemic, such as gender inequalities, must also be taken into account. Further reflection is also needed on the relationship between counseling guidelines and practices within the vulnerability approach to HIV prevention.

Enabling positive change: Progress and setbacks in HIV and sexual and reproductive health and rights

At a point in history when the future of sexual and reproductive health including HIV looks particularly uncertain, it is helpful to recognise that many of the challenges currently faced are neither new nor insurmountable. Reflecting on past achievements and lessons learned helps us to have confidence that positive change is feasible. This paper reflects on some of the changes observed in countries like India and Mozambique and identifies a range of factors which need to coalesce to enable these developments, along with specific contextual factors. It is the combination of these influences rather than any one of them alone that brought about the change in the three instances described - fostering a positive political response to HIV in its early years in India; bringing about policy reform on abortion in Mozambique; and increasing contraceptive prevalence and age at marriage in some districts in Bihar, India. Change is always fragile and susceptible to setbacks, but change-seekers can learn in the process and gain renewed hope that progress can and often does take place if they persevere.

A journey to HIV prevention research: From social psychology to social health via multidisciplinarity

This is a personal account of my research in HIV prevention from 1984 to the present day. It demonstrates my disquiet with the individualism of psychology as a way of thinking about what was needed to prevent HIV transmission. HIV prevention requires social transformation which is produced via changes in social practices and norms of communities and networks rather than by changes in behaviours of individuals. My colleagues and I developed a 'social health' model of social transformation that involves enabling communities to modify their social practices by building on emergent community responses, responses that were identified by the use of a reflexive research methodology.

Leadership emergence: the application of the Cynefin framework during a bio-social HIV/AIDS risk-reduction pilot

This article focuses on the utility of a knowledge management heuristic called the Cynefin framework, which was applied during an ongoing pilot intervention in the Limpopo province, South Africa. The intervention aimed to identify and then consolidate low-cost, innovative bio-social responses to reinforce the biomedical opportunities that now have the potential to "end AIDS by 2030″. The Cynefin framework is designed to enable leaders to identify specific decision-making domain typologies as a mechanism to maximise the effectiveness of leadership responses to both opportunities and challenges that emerge during interventions. In this instance the Cynefin framework was used to: (1) provide an indication to the project managers whether the early stages of the intervention had been effective; (2) provide the participants an opportunity to identify emergent knowledge action spaces (opportunities and challenges); and (3) categorise them into appropriate decision-making domains in preparation for the next phases of the intervention. A qualitative methodology was applied to collect and analyse the findings. The findings indicate that applying the Cynefin framework enabled the participants to situate knowledge action spaces into appropriate decision-making domains. From this participatory evaluation a targeted management strategy was developed for the next phases of the initiative. The article concludes by arguing that the Cynefin framework was an effective mechanism for situating emergent knowledge action spaces into appropriate decision-making domains, which enabled them to prepare for the next phases of the intervention. This process of responsive decision making could have utility in other development related interventions.

The dynamics of the production of AIDS-related stigma among pregnant women living with HIV/AIDS in Rio de Janeiro, Brazil

The study analyses the relationship between AIDS-related stigma and the processes of discrimination prior to diagnosis among pregnant women living with HIV/AIDS. The fieldwork involved interviews about the life trajectories of 29 pregnant women living with HIV/AIDS, recruited at two AIDS services in Rio de Janeiro, Brazil. The analysis revealed that before HIV diagnosis, social and gender inequalities experienced by these women reduced their access to material and symbolic goods that could have enhanced educational and career prospects and their ability and autonomy to exercise sexual and reproductive rights. Being diagnosed with HIV triggered fear of moral judgment and of breakdown in social and family support networks. Given these fears, pregnant women living with HIV/AIDS opt for concealment of the diagnosis. It is necessary for health services, NGOs and government agencies to work together to face the factors that fuel stigma, such as socioeconomic and gender inequalities, taboos and prejudices related to sexuality, and also develop actions to enable women to redefine the meaning of the disease.

Immigration policies and mental health morbidity among Latinos: A state-level analysis

RATIONALE

Despite abundant state-level policy activity in the U.S. related to immigration, no research has examined the mental health impact of the overall policy climate for Latinos, taking into account both inclusionary and exclusionary legislation.

OBJECTIVE

To examine associations between the state-level policy climate related to immigration and mental health outcomes among Latinos.

METHODS

We created a multi-sectoral policy climate index that included 14 policies in four domains (immigration, race/ethnicity, language, and agricultural worker protections). We then examined the relation of this policy climate index to two mental health outcomes (days of poor mental health and psychological distress) among Latinos from 31 states in the 2012 Behavioral Risk Factor Surveillance System (BRFSS), a population-based health survey of non-institutionalized individuals aged 18 years or older.

RESULTS

Individuals in states with a more exclusionary immigration policy climate had higher rates of poor mental health days than participants in states with a less exclusionary policy climate (RR: 1.05, 95% CI: 1.00, 1.10). The association between state policies and the rate of poor mental health days was significantly higher among Latinos versus non-Latinos (RR for interaction term: 1.03, 95% CI: 1.01, 1.06). Furthermore, Latinos in states with a more exclusionary policy climate had 1.14 (95% CI: 1.04, 1.25) times the rate of poor mental health days than Latinos in states with a less exclusionary policy climate. Results were robust to individual- and state-level confounders. Sensitivity analyses indicated that results were specific to immigration policies, and not indicators of state political climate or of residential segregation. No relationship was observed between the immigration policy index and psychological distress.

CONCLUSION

These results suggest that restrictive immigration policies may be detrimental to the mental health of Latinos in the United States.

Prevention literacy: community-based advocacy for access and ownership of the HIV prevention toolkit

Introduction

Critical technological advances have yielded a toolkit of HIV prevention strategies. This literature review sought to provide contextual and historical reflection needed to bridge the conceptual gap between clinical efficacy and community effectiveness (i.e. knowledge and usage) of existing HIV prevention options, especially in resource-poor settings.

Methods

Between January 2015 and October 2015, we reviewed scholarly and grey literatures to define treatment literacy and health literacy and assess the current need for literacy related to HIV prevention. The review included searches in electronic databases including MEDLINE, PsycINFO, PubMed, and Google Scholar. Permutations of the following search terms were used: “treatment literacy,” “treatment education,” “health literacy,” and “prevention literacy.” Through an iterative process of analyses and searches, titles and/or abstracts and reference lists of retrieved articles were reviewed for additional articles, and historical content analyses of grey literature and websites were additionally conducted.

Results and discussion

Treatment literacy was a well-established concept developed in the global South, which was later partially adopted by international agencies such as the World Health Organization. Treatment literacy emerged as more effective antiretroviral therapies became available. Developed from popular pedagogy and grassroots efforts during an intense struggle for treatment access, treatment literacy addressed the need to extend access to underserved communities and low-income settings that might otherwise be excluded from access. In contrast, prevention literacy is absent in the recent surge of new biomedical prevention strategies; prevention literacy was scarcely referenced and undertheorized in the available literature. Prevention efforts today include multimodal techniques, which jointly comprise a toolkit of biomedical, behavioural, and structural/environmental approaches. However, linkages to community advocacy and mobilization efforts are limited and unsustainable. Success of prevention efforts depends on equity of access, community-based ownership, and multilevel support structures to enable usage and sustainability.

Conclusions

For existing HIV prevention efforts to be effective in “real-world” settings, with limited resources, reflection on historical lessons and contextual realities (i.e. policies, financial constraints, and biomedical patents) indicated the need to extend principles developed for treatment access and treatment literacy, to support prevention literacy and prevention access as an integral part of the global response to HIV.

The limitations of 'Black MSM' as a category: Why gender, sexuality, and desire still matter for social and biomedical HIV prevention methods

The USA faces disproportionate and increasing HIV incidence rates among Black men who have sex with men (BMSM). New biomedical technologies such as pre-exposure prophylaxis (PrEP) have been developed to address their HIV risk. Very little consideration, however, has been given to the diversity obscured by 'BMSM' as a category, to how this diversity relates to men's sexual partnering strategies, or to the relevance of these issues for new HIV prevention methods. We conducted a community-based ethnography from June 2013 to May 2014 documenting factors that affect the acceptance of and adherence to PrEP among BMSM. We conducted in-depth interviews with 31 BMSM and 17 community stakeholders, and participant observation. To demonstrate the diversity of social identities, we present a taxonomy of indigenous categories organised along the axes of sexual identity, sexual positioning, and gender performance. We analyse how HIV prevention strategies, such as PrEP, may be more effective if programmes consider how gender, sexuality, and sexual desire shape sexual partnering strategies. This article underlines the importance of attending to the diversity of sexual and social subjectivities among BMSM, of bringing the study of sexuality back into HIV prevention, and of integrating biomedical prevention approaches into community-based programmes.

'Protective' silence surrounding AIDS: Reasons and implications of non-disclosure among pregnant women living with HIV in Rio de Janeiro (Brazil)

The persistence of stigma surrounding AIDS remains a challenge in the epidemic's fourth decade. Based on qualitative research, this study analyses how pregnant women living with HIV/AIDS (PWLHA) experience and cope with AIDS stigma. A total of 29 semi-structured interviews were conducted with PWLHA focusing on socioeconomic profiles, the contexts in which they discovered HIV infection, experiences with health-care sites and ways of dealing with AIDS-related stigma. We recruited PWLHA at two prevention of mother-to-child transmission sites in Rio de Janeiro, Brazil. The PWLHA's testimony indicates that access to care and treatment has a profound effect on the deconstruction of their understanding of AIDS as a fatal disease. However, fear of AIDS stigma is still predominant. The law guarantees HIV non-disclosure, and women see it as a way to protect themselves from discrimination. We argue, however, that the silence surrounding HIV diagnosis perpetuates the psychosocial and structural mechanisms that reproduce stigma. We conclude that diverse sectors of society, including health-care facilities, must be involved in confronting stigma by demystifying AIDS, improving patients' knowledge of their rights, and increasing their access to material and symbolic goods.

Children and Adolescents with Perinatal HIV-1 Infection: Factors Associated with Adherence to Treatment in the Brazilian Context

Challenges to the adherence to combination antiretroviral therapy among the pediatric population should be understood in the context of the trajectories of families, their interaction with healthcare services, and their access to material and symbolic goods. The present study analyzed individual, institutional and social factors that might be associated with the caregivers’ role in the treatment adherence of children and adolescents living with HIV (CALHIV). Based on semi-structured interviews and questionnaires applied to 69 caregivers seen at pediatric AIDS services of five Brazilian macro-regions, we observed that adherent caregivers had better acceptance of diagnosis and treatment, were less likely to face discrimination and social isolation secondary to AIDS-related stigma and tended to believe in the efficacy of treatment, and to be more optimistic about life perspectives of CALHIV. Interventions aiming to improve adherence and to promote the health of CALHIV should take in consideration the interplay of such different factors.