Violence victimization after HIV infection in a US probability sample of adult patients in primary care

HIV disclosure without consent linked to increased violence against women living with HIV in a Canadian setting

Our study examined the association between HIV disclosure without consent and verbal and/or physical violence due to HIV status among women living with HIV (WLWH). This study draws on baseline data of a sample (N = 316) from SHAWNA, a longitudinal community-based open cohort with WLWH in Metro Vancouver, Canada (2010-2019). Bivariate and multivariable logistic regression was used to investigate factors associated with physical and/or verbal violence due to HIV status. Adjusted odds ratios (AOR) and 95% confidence intervals [95%CIs] are reported. In total, 46.5% experienced non-consensual disclosure of HIV status without consent and 34.2% experienced physical and/or verbal violence related to HIV status in their lifetime. In multivariable analysis, HIV disclosure without consent was associated with increased odds of experiencing HIV-related physical and/or verbal violence (AOR: 7.46[4.21-13.21]). Lifetime exposure to homelessness was also associated with increased odds of physical and/or verbal violence due to HIV status (AOR: 2.15[1.03-4.49]). This research underscores the reality of HIV stigmatization and criminalization and suggests a critical need to remove HIV disclosure from the reach of criminal law and ensure women's rights to confidentiality. Governments and organizations must work to identify and address the drivers of various levels of stigma and gender-based violence and invest in inclusive, trauma-informed, culturally safe support and care programs and policies designed in collaboration with WLWH.

Prevalence and Social-Structural Correlates of Gender-Based Violence Against Women Living With HIV in Metro Vancouver, Canada

Violence experienced by cisgender (cis) and gender minority women living with HIV is known to be high. More work is needed to better understand how to support women living with HIV who have experienced violence. The objectives of this study are therefore to identify the prevalence and correlates of violence by any perpetrator among women living with HIV in a Canadian setting. Data were drawn from 9 years (January, 2010 to February, 2019) of a longitudinal community-based open cohort study of 350+ cis and trans women living with HIV who were living and/or accessed care in Metro Vancouver, Canada (Sexual Health and HIV/AIDS: Women's Longitudinal Needs Assessment "SHAWNA"). Participants completed baseline and biannual follow-up interviews. Bivariate and multivariable logistic regression with generalized estimating equations (GEE) were performed to identify correlates of recent (last 6 months) violence (physical and/or sexual) by any perpetrator. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CIs) are presented. At baseline, prevalence of violence was high: 95.5% (recent = 19.4%) of participants reported lifetime physical and/or sexual violence, 94.8% (recent = 17.9%) reported lifetime physical violence, and 84.5% (recent = 5.7%) reported lifetime sexual violence. In multivariable logistic regression with GEE, the following variables were associated with higher odds of recent physical/sexual violence: youth (<30 years) (AOR: 1.60, 95% CI [1.15, 2.22]), recent unstable housing/homelessness (AOR: 1.96, 95% CI [1.30, 2.97]), recent food insecurity (AOR: 1.57, 95% CI [1.13, 2.17]), recent incarceration (AOR: 1.85, 95% CI [1.18, 2.91]), recent opioid use (AOR: 1.38, 95% CI [1.04, 1.82]), recent stimulant use (AOR: 2.48, 95% CI [1.72, 3.56]), and lifetime HIV status disclosure without consent (AOR: 1.59, 95% CI [1.13, 2.24]). Trauma- and violence-informed (TVI) policies that include a focus on confidentiality and safe disclosure practices should be integrated into existing housing, incarceration, and harm reduction programs, and HIV care and practice for women living with HIV. Programs and policies that address high levels of violence remain critical.

Study protocol: A randomised trial of the effectiveness of the Common Elements Treatment Approach (CETA) for improving HIV treatment outcomes among women experiencing intimate partner violence in South Africa

INTRODUCTION

Intimate partner violence (IPV) is a barrier to consistent HIV treatment in South Africa. Previous trials have established that the Common Elements Treatment Approach (CETA), a cognitive-behavioural-based intervention, is effective in reducing mental and behavioural health problems but has not been trialled for effectiveness in improving HIV outcomes. This paper describes the protocol for a randomised trial that is testing the effectiveness of CETA in improving HIV treatment outcomes among women experiencing IPV in South Africa.

METHODS AND ANALYSIS

We are conducting a randomised trial among HIV-infected women on antiretroviral therapy, who have experienced sexual and/or physical IPV, to test the effect of CETA on increasing retention and viral suppression and reducing IPV. Women living with HIV who have an unsuppressed viral load or are at high risk for poor adherence and report experiencing recent IPV, defined as at least once within in the last 12 months, will be recruited from HIV clinics and randomised 1:1 to receive CETA or an active attention control (text message reminders). All participants will be followed for 24 months. Follow-up HIV data will be collected passively using routinely collected medical records. HIV outcomes will be assessed at 12 and 24 months post-baseline. Questionnaires on violence, substance use and mental health will be administered at baseline, post-CETA completion and at 12 months post-baseline. Our primary outcome is retention and viral suppression (<50 copies/mL) by 12 months post-baseline. We will include 400 women which will give us 80% power to detect an absolute 21% difference between arms. Our primary analysis will be an intention-to-treat comparison of intervention and control by risk differences with 95% CIs.

ETHICS AND DISSEMINATION

Ethics approval provided by University of the Witwatersrand Human Research Ethics Committee (Medical), Boston University Institutional Review Board and Johns Hopkins School Institutional Review Board. Results will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04242992.

Discourse, Difference, and Divergence: Exploring Media Representations and Online Public Sentiments toward Marginalized Urban Communities in Jamaica during the COVID-19 Pandemic

Despite lacking the resources to adequately adhere to public health protocols, urban residents belonging to impoverished communities in Kingston, Jamaica were prominently featured in local news reports that highlighted their breaches of social distancing. These reports generated an overwhelmingly prejudiced online social discourse, characterized by derogatory and dehumanizing remarks. This research aims to explore the ways media representations of calls for social distancing have unearthed latent social cleavages and contributed to the othering of Kingston’s poor. A thematic analysis was used to understand the nature of the public response to these news reports. The comments were manually coded, and emergent themes were classified based on the sentiments expressed. The comments generated evoked class, place, race, and political tensions, potentially perpetuating the public perception of vulnerable groups as the ‘threatening other’. These comments possibly represent deeper problems associated with the social divergence of Jamaican society. The lack of sensitivity exhibited shows a general disregard for the stark social realities commonly experienced by subaltern groups. These findings suggest media coverage promoting public safety, while important, may inadvertently lead to heightened social tensions and perpetuate social stigmas against marginalized groups, potentially stirring social divergence and countering efforts toward inclusiveness and integration.

Lifetime sexual violence exposure in women compromises systemic innate immune mediators associated with HIV pathogenesis: A cross-sectional analysis

OBJECTIVES

Violence and HIV/AIDS syndemic highly prevalent among women impairs HIV prevention efforts. Prolonged exposure to violence results in physical trauma and psychological distress. Building on previous findings regarding genital immune dysregulation following sexual abuse exposure, we investigate here whether systemic changes occur as well.

METHODS

Using the Women's Interagency HIV Study repository, 77 women were stratified by HIV serostatus and categorized into four subgroups: (1) no sexual abuse history and lower depression score (Control); (2) no sexual abuse history but higher depression score (Depression); (3) high sexual abuse exposure and lower depression score (Abuse); (4) high sexual abuse exposure and higher depression score (Abuse + Depression). Inflammation-associated immune biomarkers (TNF-α, IL-6, IL-1α, IL-1β, TGF-β, MIP-3α, IP-10, MCP-1, and Cathepsin-B) and anti-inflammatory/anti-HIV biomarkers (Secretory leukocyte protease inhibitor, Elafin, human beta-defensin-2 (HBD-2), alpha-defensins 1-3, Thrombospondin, Serpin-A1, and Cystatin-C) were measured in plasma using enzyme-linked immunosorbent assay. Within each HIV serostatus, differences in biomarker levels between subgroups were evaluated with Kruskal-Wallis and Dunn's test with Bonferroni correction. Spearman correlations between biomarkers were assessed for each subgroup.

RESULTS

Compared to the Control and Depression groups, Abuse + Depression was associated with significantly higher levels of chemokines MIP-3α and IP-10 (p < 0.01) and lower levels of inflammatory cytokine IL-1β (p < 0.01) in the HIV-uninfected population. Human beta-defensin-2 was lowest in the Abuse + Depression group (p < 0.05 versus Depression). By contrast, among HIV-infected, Abuse and Abuse + Depression were associated with lower levels of MIP-3α (p < 0.05 versus Control) and IP-10 (p < 0.05, Abuse versus Control). Inflammatory cytokine IL-6 was higher in both Abuse groups (p < 0.05 versus Control), while Elafin was lowest in the Abuse + Depression group (p < 0.01 versus Depression).

CONCLUSION

We report compromised plasma immune responses that parallel previous findings in the genital mucosa, based on sexual abuse and HIV status. Systemic biomarkers may indicate trauma exposure and impact risk of HIV acquisition/transmission.

Trends of HIV/AIDS knowledge and attitudes among Nigerian women between 2007 and 2017 using Multiple Indicator Cluster Survey data

BACKGROUND

Globally, Nigeria ranks third among the countries with the highest number of People Living with HIV (PLHIV). Given that HIV/AIDS knowledge is a key factor that determines the risk of transmission and certain attitudes towards PLHIV, there is a need to understand the trend of HIV knowledge within the population for the purpose of assessing the progress and outcome of HIV prevention strategies. The aim of the study was to understand the trends of HIV/AIDS knowledge and attitude towards PLHIV between 2007 to 2017 among Nigerian women, and to investigate change in the factors associated with HIV/AIDS knowledge and attitude towards PLHIV over years.

METHODS

Data were derived from three Nigerian Multiple Indicator Cluster Surveys (2007, 2011 and 2016-2017) among women aged 15-49 years old from each geo-political zone (South South, South East, South West, North East, North West, North Central) in Nigeria. Participants who did not answer questions related to HIV/AIDS knowledge and attitude were excluded from the study. The final sample sizes were 17,733 for 2007, 26,532 for 2011 and 23,530 for 2017. In descriptive statistics, frequencies represented the study sample, while percentages represented weighted estimates for the population parameters. Rao-Scott chi-square test for complex survey design studies was used to assess bivariable associations. Factors associated with outcome variables were examined using the survey-weighted multivariable logistic regression models for the complex survey design while controlling for potential confounding variables.

RESULTS

There was a relatively high level of HIV/AIDS knowledge level in 2007 and 2016-2017 surveys (64.6 and 64.1%, respectively), however a decrease in HIV/AIDS knowledge trend was observed in 2011 (45.6%). The positive attitude towards PLHIV progressively increased across the years (from 40.5 to 47.0% to 53.5%). Multivariable analysis revealed that women who had a higher educational level, higher wealth index, and lived in urban areas had higher odds for HIV/AIDS knowledge and positive attitude towards PLHIV across the years. In addition, the Northern zones had predominantly higher knowledge and attitude levels.

CONCLUSIONS

Our study found increasing tendency for high HIV/AIDS knowledge and positive attitude towards PLHIV over the years. Women's age, wealth index, education level and residence were consistently associated with knowledge and attitude over the years. There is a need for more pragmatic HIV/AIDS-related knowledge action plan to target to cover all age groups, all geo-political zones while paying close attention to the rural areas and the less educated women. In addition, more replicative studies of HIV/AIDS knowledge and attitude trends is crucial in monitoring of the progress of HIV interventions in the country in the coming years.

HIV-related stigma in the UK then and now: to what extent are we on track to eliminate stigma? A qualitative investigation

Background

The introduction of effective antiretroviral treatment in the late 1990s led to the perception that HIV was a chronic but manageable condition. Nevertheless, stigma remains one of the major hurdles for people living with HIV (PLWH) to accessing healthcare and biomedical preventions. Thus, Fast Track Cities has set a target of zero HIV discrimination by 2030 as part of its strategy to end HIV transmission.

Methods

Fifty-three participants from the United Kingdom, including PLWH (n = 21, 40%), health and social care workers (n = 24, 45%), and charity workers and activists (n = 13, 25%), were recruited. Semi-structured interviews investigated stigma and discrimination, focusing on both before and after the widespread use of effective antiretroviral treatment in the late 1990s. Data were analysed using a thematic approach.

Results

Before effective antiretroviral treatment narratives were shaped by two main themes: 1) the media’s role in influencing public opinion and contributing to misunderstandings of HIV transmission; and 2) personal experiences of HIV-related stigma, which for PLWH included incidents of physical violence and aggression, as well as fears of their HIV status being publicised. Contemporary narratives on stigma experiences were organised around four themes: 1) discrimination in healthcare settings; 2) stigma amongst men who have sex with men (MSM); 3) stigma towards African and Afro-Caribbean PLWH; and 4) the limits of change in public HIV-related knowledge and attitudes. Contemporary narratives indicated a reduction in enacted stigma, but continued anticipation of discrimination and self-reported shame, particularly in MSM and African and Afro-Caribbean PLWH.

Conclusion

The nature of stigma against those with HIV has evolved. The intersection of PLWH and minority groups (e.g. MSM and African and Afro-Caribbean persons) may enhance anticipatory and internalised stigma, with some suggestion that this may contribute to reduced engagement in HIV care and prevention services. Our findings indicate the need for further research in this area, as well as proactive interventions with community groups to enhance knowledge of HIV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11000-7.

Physical, Emotional, and Psychosocial Challenges Associated with Daily Dosing of HIV Medications and Their Impact on Indicators of Quality of Life: Findings from the Positive Perspectives Study

To assess challenges with daily oral antiretroviral therapy (ART), we analyzed data for 2389 participants in the 2019 Positive Perspectives survey of people living with HIV in 25 countries. ART-related challenges reported included difficulty swallowing pills (33.1% [790/2389]); stress from daily dosing routine (33.3% [795/2389]); bad memories from daily intake of HIV medication (35.1%[839/2389]), and concern “that having to take pills every day means a greater chance of revealing my HIV status to others” (37.9% [906/2389]). Individuals who felt empowered by daily oral dosing [“taking my pill(s) every day reassures me that my HIV is being kept under control”] had 69% higher odds of optimal overall health (AOR 1.69, 95% CI 1.40–2.04). Conversely, odds of optimal overall health were lower among those who felt daily pill intake “limits my day-to-day life” (AOR 0.53, 95% CI 0.44–0.64). These findings show that there is need for increased flexibility of ART delivery to meet diverse patient needs.

Psychometric Validation of the Brazilian Portuguese Version of the Derriford Appearance Scale-24 (DAS-24) for People Living with HIV/AIDS

The changes in appearance of people living with HIV/AIDS (PLHA) interferes with how people around them react to their body, how social interactions take place, and how each person perceives and accepts their body. The definition of itself can be severely challenged when the body changes as a result of illness and the person does not look healthier anymore. People living with HIV/AIDS (PLHA) are an especially vulnerable group when it comes to “distress” and the psychosocial impact of appearance, yet the assessment of body image changes in these people was subjective in Brazil. The aim of this paper was to assess the psychometric properties of the Brazilian version of Derriford Appearance Scale 24 (DAS-24) for a sample of Brazilians living with HIV/AIDS. A sample of 400 patients were recruited from an HIV/AIDS ambulatory, aged between 18 and 78 years, of both sexes. The psychometric properties of DAS-24 were investigated while using confirmatory factor analysis (CFA), with unweighted least square estimation and listwise deletion for missing data. The adjustment of three structural models previously established for DAS-24 (single-factor, two-factor, and three-factor) was investigated. Evidences of construct validity—convergent and discriminant—and internal consistency—Cronbach’s alpha and construct reliability—were also generated for the measure model. The results showed that the one-factor model had the best adjustment, after eliminating items 8, 17, and 20, and accepting the covariance of errors between items 4 and 10; 9 and 23; 11 and 14; and, 14 and 22. Additionally, validity and reliability evidence were satisfactory for the model. The Brazilian Portuguese version of DAS-24 seems to be a psychometrically sound scale for measuring body image distress for people living with HIV/AIDS (PLHA).

Typologies of violence against women in Brazil: A latent class analysis of how violence and HIV intersect

We address the limited understanding around the overlap between violence and HIV in Brazil. Data was from two clinic-based samples of HIV-positive (n = 1534) and HIV-negative women (n = 1589) in São Paulo and Porto Alegre. We conducted latent class analysis and identified violence typologies by type of violence, life course timing, frequency, and perpetrator, stratified by city and HIV-status. Overall, HIV-positive women experienced more lifetime physical and sexual violence than HIV-negative women. Twelve unique violence latent classes were identified. In São Paulo, HIV-positive women were likely to have endured physical violence several times (Conditional Probability [CP]: 0.80) by an intimate partner (CP: 0.85), and sexual violence several times (CP: 0.46) by an intimate partner (CP: 0.62). In Porto Alegre, HIV-positive women endured physical violence several times (CP: 0.80) by an intimate partner (CP: 0.70) during childhood/adolescence (CP: 0.48), and sexual violence several times (CP: 0.54) by an intimate partner (CP: 0.60). Findings inform interventions to educate around gender equity, violence, and the health effects of violence including HIV, integrate HIV and violence services, and improve the provision of bio-medical HIV prevention among HIV-negative women who experience violence.

A longitudinal study of associations between HIV-related stigma, recent violence and depression among women living with HIV in a Canadian cohort study

INTRODUCTION

Women living with HIV (WLHIV) experience stigma and elevated exposure to violence in comparison with HIV-negative women. We examined the mediating role of experiencing recent violence in the relationship between stigma and depression among WLHIV in Canada.

METHODS

We conducted a cohort study with WLHIV in three Canadian provinces. Recent violence was assessed through self-reported experiences of control, physical, sexual or verbal abuse in the past three months. At Time 1 (2013-2015) three forms of stigma were assessed (HIV-related, racial, gender) and at Time 2 (2015-2017) only HIV-related stigma was assessed. We conducted structural equation modelling (SEM) using the maximum likelihood estimation method with Time 1 data to identify direct and indirect effects of gender discrimination, racial discrimination and HIV-related stigma on depression via recent violence. We then conducted mixed effects regression and SEM using Time 1 and Time 2 data to examine associations between HIV-related stigma, recent violence and depression.

RESULTS

At Time 1 (n = 1296), the direct path from HIV-related stigma (direct effect: β = 0.200, p < 0.001; indirect effect: β = 0.014, p < 0.05) to depression was significant; recent violence accounted for 6.5% of the total effect. Gender discrimination had a significant direct and indirect effect on depression (direct effect: β = 0.167, p < 0.001; indirect effect: β = 0.050, p < 0.001); recent violence explained 23.15% of the total effect. Including Time 1 and Time 2 data (n = 1161), mixed-effects regression results indicate a positive relationship over time between HIV-related stigma and depression (Acoef: 0.04, 95% CI: 0.03, 0.06, p < 0.001), and recent violence and depression (Acoef: 1.95, 95% CI: 0.29, 4.42, p < 0.05), controlling for socio-demographics. There was a significant interaction between HIV-related stigma and recent violence with depression (Acoef: 0.04, 95% CI: 0.01, 0.07, p < 0.05). SEM analyses reveal that HIV-related stigma had a significant direct and indirect effect on depression over time (direct effect: β = 0.178, p < 0.001; indirect effect: β = 0.040, p < 0.001); recent violence experiences accounted for 51% of the total effect.

CONCLUSIONS

Our findings suggest that HIV-related stigma is associated with increased experiences of recent violence, and both stigma and violence are associated with increased depression among WLHIV in Canada. There is an urgent need for trauma-informed stigma interventions to address stigma, discrimination and violence.

Violence towards people with mental illness: Assessment, risk factors, and management

AIM

Violence is an important problem for clinicians, for public health, and for victims. Aside from greater risk of perpetrating violence, people with mental illness are also more commonly victimized than the general population. However, guidance on the assessment and management of violent victimization in clinical settings is limited.

METHODS

We carried out a review and consolidation of clinical and research literature on violent victimization in people with mental illness.

RESULTS

Assessment of mental state in someone who has been victimized should evaluate both historical factors (such as pattern, timing, perpetrator characteristics, and contextual factors) and clinical factors (including affective and cognitive changes).

CONCLUSION

Concerted clinical and policy attention to factors that might increase vulnerability, such as alcohol use, lack of support, and the social environment, could improve outcomes.

Interventions that Address Intimate Partner Violence and HIV Among Women: A Systematic Review

Recognizing the high prevalence of human immunodeficiency virus (HIV)-positive women and girls who are either at risk for or suffer from intimate partner violence (IPV) and the overlapping challenges posed by both public health issues, the White House established an Interagency Federal Working Group to address the intersection of both public health issues in 2012. We conducted this systematic review in response to the Working Group's charge to identify and describe interventions that address both IPV and HIV among women. We identified 14 studies that met our inclusion criteria, including seven studies (nine unique intervention arms) that significantly affected at least one outcome related to IPV and HIV. In this article, we examine the characteristics of these studies including core components, intervention populations, and effectiveness data. We highlight opportunities to improve the effectiveness of existing interventions, guide future research about IPV and HIV, and inform prevention programmatic delivery. This knowledge will improve the lives of populations at risk, reduce gender-related health disparities, and ultimately reduce the societal burden of both public health issues.

Positive sexuality: HIV disclosure, gender, violence and the law-A qualitative study

While a growing body of research points to the shortcomings of the criminal law in governing HIV transmission, there is limited understanding of how cis and trans women living with HIV (WLWH) negotiate their sexuality and HIV disclosure in a criminalized environment. Given the ongoing criminalization of HIV non-disclosure and prevalence of gender-based violence, there is a critical need to better understand the dynamics of negotiating sexual relationships and HIV disclosure among WLWH. We conducted 64 qualitative interviews with cis and trans WLWH in Vancouver, Canada between 2015 and 2017. The interviews were conducted by three experienced researchers, including a cis and a trans WLWH using a semi-structured interview guide. Drawing on a feminist analytical framework and concepts of structural violence, the analysis sought to characterize the negotiation of sexual relationships and HIV disclosure among WLWH in a criminalized setting. For many participants their HIV diagnosis initially symbolized the end of their sexuality due to fear of rejection and potential legal consequences. WLWH recounted that disclosing their HIV status shifted the power dynamics in sexual relationships and many feared rejection, violence, and being outed as living with HIV. Participants' narratives also highlighted that male condom refusal was common and WLWH were not only subjected to the gendered interpersonal violence of male condom refusal but also to the structural violence of legislation that requires condom use but fails to account for the gendered power imbalance that shapes condom negotiation. Despite frequently being represented as a law that 'protects' women, our findings indicate that the criminalization of HIV non-disclosure constitutes a form of gendered structural violence that exacerbates risk for interpersonal violence among WLWH. In line with recommendations by, the WHO and UNAIDS these findings demonstrate the negative impacts of regulating HIV prevention through the use of criminal law for WLWH.

Doing battle with "the monster:" how high-risk heterosexuals experience and successfully manage HIV stigma as a barrier to HIV testing

Background

Annual HIV testing is recommended for populations at-risk for HIV in the United States, including heterosexuals geographically connected to urban high-risk areas (HRA) with elevated rates of HIV prevalence and poverty, who are primarily African American/Black or Hispanic. Yet this subpopulation of “individuals residing in HRA” (IR-HRA) evidence low rates of regular HIV testing. HIV stigma is a recognized primary barrier to testing, in part due to its interaction with other stigmatized social identities. Guided by social-cognitive and intersectionality theories, this qualitative descriptive study explored stigma as a barrier to HIV testing and identified ways IR-HRA manage stigma.

Methods

In 2012-2014, we conducted in-depth qualitative interviews with 31 adult IR-HRA (74% male, 84% African American/Black) with unknown or negative HIV status, purposively sampled from a larger study for maximum variation on HIV testing experiences. Interviews were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach that was both theory-driven and inductive.

Results

Stigma was a primary barrier to HIV testing among IR-HRA. In the context of an under-resourced community, HIV stigma was experienced as emerging from, and being perpetuated by, health care organizations and educational institutions, as well as community members. Participants noted it was “better not to know” one’s HIV status, to avoid experiencing HIV-related stigma, which could interact with other stigmatized social identities and threaten vital social relationships, life chances, and resources. Yet most had tested for HIV previously. Factors facilitating testing included health education to boost knowledge of effective treatments for HIV; understanding HIV does not necessitate ending social relationships; and tapping into altruism.

Conclusions

In the context of economic and social inequality, HIV stigma operates on multiple, intersecting layers. IR-HRA struggle with an aversion to HIV testing, because adopting another stigmatized status is dangerous. They also find ways to manage stigma to engage in testing, even if not at recommended levels. Findings highlight strategies to reduce HIV stigma at the levels of communities, institutions, and individuals to improve rates of annual HIV testing necessary to eliminate HIV transmission and reduce HIV-related racial and ethnic health disparities among IR-HRA.

Intersectional stigma among midlife and older Black women living with HIV

HIV-related stigma is a barrier to the prevention and treatment of HIV. For midlife and older Black women, the nature and intensity of HIV-related stigma may be compounded by their multiple marginalised social status based on gender, race, and age. We examined the perceptions and experiences of HIV-related stigma among midlife and older Black women living in Prince George's County, Maryland, USA. Between 2014 and 2015, we conducted semi-structured interviews with a sample of 35 midlife and older Black women living with HIV. Using a modified grounded theory approach, we explored emergent themes related to the manifestation and experience of intersectional stigma and changes in stigma experience over time. Our findings suggest that intersectional stigma is a central feature in midlife and older Black women's lives, with women reporting experiences of intersectional stigma at the interpersonal/familial, community, and institutional/structural levels. Although women acknowledged gradual acceptance of their HIV-positive status over time, they continued to experience negative responses related to gender, race, age, and disease. Our findings indicate that a more robust understanding of the impact of HIV-related stigma requires work to consider the complex manifestations of intersectional stigma among an increasingly aging population of Black women in the USA.

Developing a community-level anti-HIV/AIDS stigma and homophobia intervention in new York city: The project CHHANGE model

HIV/AIDS stigma and homophobia are associated with significant negative health and social outcomes among people living with HIV/AIDS (PLWHA) and those at risk of infection. Interventions to decrease HIV stigma have focused on providing information and education, changing attitudes and values, and increasing contact with people living with HIV/AIDS (PLWHA), activities that act to reduce stereotyped beliefs and prejudice, as well as acts of discrimination. Most anti-homophobia interventions have focused on bullying reduction and have been implemented at the secondary and post-secondary education levels. Few interventions address HIV stigma and homophobia and operate at the community level. Project CHHANGE, Challenge HIV Stigma and Homophobia and Gain Empowerment, was a community-level, multi-component anti-HIV/AIDS stigma and homophobia intervention designed to reduce HIV stigma and homophobia thus increasing access to HIV prevention and treatment access. The theory-based intervention included three primary components: workshops and trainings with local residents, businesses and community-based organizations (CBO); space-based events at a CBO-partner drop-in storefront and "pop-up" street-based events and outreach; and a bus shelter ad campaign. This paper describes the intervention design process, resultant intervention and the study team's experiences working with the community. We conclude that CHHANGE was feasible and acceptable to the community. Promoting the labeling of gay and/or HIV-related "space" as a non-stigmatized, community resource, as well as providing opportunities for residents to have contact with targeted groups and to understand how HIV stigma and homophobia relate to HIV/AIDS prevalence in their neighborhood may be crucial components of successful anti-stigma and discrimination programming.

Stigma kills! The psychological effects of emotional abuse and discrimination towards a patient with HIV in Uganda

Our patient is a 58-year-old Ugandan woman. After her husband's death in 1994, the patient was forced to leave her home by her late husband's family and arrangements were made for her mother to provide care until her inevitable death. The patient suffered from multiple mental health disturbances as a result of discrimination. Socially isolated after years of self-neglect, she prepared to overdose. In 2007, she became open regarding her status after receiving psychosocial support from various sources. She opened her home as an HIV clinic with the help of a local doctor, and subsequently the majority of her psychological symptoms were resolved. This case illustrates the negative impact that stigma and discrimination can have on mental and consequently physical health, both acutely and chronically. It also highlights the importance of social and psychological support in maintaining the well-being of patients with HIV globally.

Intimate Partner Violence, Depression, and Quality of Life among Women Living with HIV/AIDS in a Coastal City of South India

BACKGROUND

Intimate partner violence (IPV) is a severe form of abuse prevalent in urban and rural areas of India with its effects on mental and physical health of the person receiving it, leading to a poorer quality of life.

METHODS

A cross-sectional study was conducted among 99 women living with HIV, and information was collected using abuse assessment scale. The data were entered and analyzed using SPSS version 17.0.

RESULTS

The IPV was reported by 19.2% of the respondents, of which psychological (14.1%) was most common followed by physical (4.1%) and sexual abuse (1.0%). The experience of IPV was significantly associated with socioeconomic status, number of children, marital status, and CD4 counts of the participants.

CONCLUSION

The prevalence of IPV in our study was found to be less compared to previous studies, however, there were significant association among factors such as socioeconomic status, CD4 counts, and marital status of the participants.

Barriers to HIV testing, linkage to care, and treatment adherence: a cross-sectional study from a large urban center of Brazil

OBJECTIVE

Early, continued engagement with the HIV treatment continuum can help achieve viral suppression, though few studies have explored how risk factors for delays differ across the continuum. The objective of this study was to identify predictors of delayed diagnosis, delayed linkage to care, and nonadherence to treatment in the city of Salvador, Bahia, Brazil.

METHODS

Data were collected during 2010 in a cross-sectional study with a sample (n = 1 970) of HIV-infected individuals enrolled in care. Multiple logistic regression analyses identified sociodemographic variables, behaviors, and measures of health service quality that were associated with delayed diagnosis, delayed linkage to care, and treatment nonadherence.

RESULTS

For delayed diagnosis, male gender (adjusted odds ratio (AOR), 3.02; 95% confidence interval (CI), 2.0-4.6); age 45 years and older (AOR, 1.67; 95% CI, 1.1-2.5); and provider-initiated testing (AOR, 3.00; 95% CI, 2.1-4.4) increased odds, while drug use (AOR, 0.29; 95% CI, 0.2-0.5) and receiving results in a private space (AOR, 0.37; 95% CI, 0.2-0.8) decreased odds. For delayed linkage to care, unemployment (AOR, 1.42; 95% CI, 1.07-1.9) and difficulty understanding or speaking with a health care worker (AOR, 1.61; 95% CI, 1.2-2.1) increased odds, while posttest counseling (AOR, 0.49; 95% CI, 0.3-0.7) decreased odds. For nonadherence, experiencing verbal or physical discrimination related to HIV (AOR, 1.94; 95% CI, 1.3-3.0) and feeling mistreated or not properly attended to at HIV care (AOR, 1.60; 95% CI, 1.0-2.5) increased odds, while posttest counseling (AOR, 0.34; 95% CI, 0.2-0.6) decreased odds.

CONCLUSIONS

More attention is needed on how policies, programs, and research can provide tailored support across the treatment continuum.

Disciplining Bodies, Desires and Subjectivities: Sexuality and HIV-Positive Women

Very little is known about the sexuality of women who are living with HIV, outside the context of risk prevention and education. Available research in the first-world context shows that, although most women continue to be sexually active following diagnosis, decreased sexual functioning is very common and more prevalent than among HIV-positive men. The present multi-site Canadian study is concerned with the ways in which women’s sexuality is transformed by the experience of living with HIV. Semi-structured interviews with 20 women were analysed using thematic decomposition, an analytic technique that combines discursive approaches with thematic analysis. The women in this study construct HIV as inhibiting in relation to sexuality. A predominant discourse of disciplining bodies, desires and subjectivities emerges, which centers on the restrictions imposed by an HIV-positive diagnosis. The following discursive constructions, in particular, emerge from the women’s accounts: diminished spontaneity, foreclosed (provisional) sexual freedom, foreclosed power, foreclosed flirtation, inciting violence, (un)natural sex, responsibility imperatives, muted/mutated sexuality, and diminished intimacy. The women’s predominant positioning within AIDS discourses as conduits of transmission, the relative neglect of women’s psychological and sexual health concerns in both research and public health agendas, and women’s relatively anomalous standing in AIDS communities imposes limits on bodies, lives, and subjectivities. These are reflected in these women’s accounts, wherein a focus on protecting others frequently impedes access to fulfilling (and safe) sexual and emotional relationships.

Puerto Rican Drug Users' Experiences of Physical and Sexual Abuse

This study examines gender and developmental stage differences in physical and sexual abuse among Puerto Rican drug users. A structured questionnaire was administered to 799 participants in New York and 382 in Puerto Rico. Qualitative data were collected through in-depth life histories with 21 participants. Study participants included 297 female and 884 male Puerto Rican drug injectors and crack smokers. Females were significantly more likely than males to report physical abuse by a family member in childhood and unwanted sex in childhood, adolescence, and adulthood. Qualitative findings describe abuse in the contexts of family, drug dealing, drug paraphernalia possession, and sex work.

Beyond Knowledge and Awareness: Addressing Misconceptions in Ghana's Preparation towards an Outbreak of Ebola Virus Disease

Background

Ebola Virus Disease (EVD) is not new to the world. However, the West African EVD epidemic which started in 2014 evolved into the largest, most severe and most complex outbreak in the history of the disease. The three most-affected countries faced enormous challenges in stopping the transmission and providing care for all patients. Although Ghana had not recorded any confirmed Ebola case, social factors have been reported to hinder efforts to control the outbreak in the three most affected countries. This qualitative study was designed to explore community knowledge and attitudes about Ebola and its transmission.

Methods

This study was carried out in five of the ten regions in Ghana. Twenty-five focus group discussions (N = 235) and 40 in-depth interviews were conducted across the five regions with community members, stakeholders and opinion leaders. The interviews were recorded digitally and transcribed verbatim. Framework analysis was adopted in the analysis of the data using Nvivo 10.

Results

The results showed a high level of awareness and knowledge about Ebola. The study further showed that knowledge on how to identify suspected cases of Ebola was also high among respondents. However, there was a firm belief that Ebola was a spiritual condition and could also be transmitted through air, mosquito bites and houseflies. These misconceptions resulted in perceptions of stigma and discrimination towards people who may get Ebola or work with Ebola patients.

Conclusion

We conclude that although knowledge and awareness about Ebola is high among Ghanaians who participated in the study, there are still misconceptions about the disease. The study recommends that health education on Ebola disease should move beyond creating awareness to targeting the identified misconceptions to improve future containment efforts.

HIV/AIDS Related Stigma and Discrimination against PLWHA in Nigerian Population

BACKGROUND

HIV/AIDS remain a major public health concern in Nigeria. People living with HIV/AIDS (PLWHA) face not only personal medical problems but also social problems associated with the disease such as stigma and discriminatory attitudes. This study provides an insight into HIV/AIDS related stigma and discrimination against PLWHA in Nigeria.

METHODS

The data for this study was extracted from the 2013 Nigeria Demographic and Health Survey conducted by the National Population Commission. All men and women aged 15-49 years, permanent residents and visitors of the households were eligible for the interview. Several questionnaires were used in the survey, some covering questions on HIV/AIDS.

RESULTS

A total of 56 307 men and women aged 15-49 years participated in this national survey. About half of the population in Nigeria have HIV stigma. Younger persons, men, those without formal education and those within poor wealth index are more likely to have stigma towards PLWHA. In addition, married people are more likely to have stigma on PLWHA and are more likely to blame PLWHA for bringing the disease to the community. Also about half of the population discriminates against PLWHA. However, those with higher levels of education and those from higher wealth index seem to be more compassionate towards PLWHA. About 70% in the population are willing to care for relative with AIDS, even more so among those with higher level of education.

CONCLUSION

There is a high level of HIV stigma and discrimination against PLWHA in the Nigerian population. Education seems to play a major role in the society with respect to HIV stigma and discrimination against PLWHA. Educating the population with factual information on HIV/AIDS is needed to reduce stigma and discrimination towards PLWHA in the community.

"Violence. Enough already": findings from a global participatory survey among women living with HIV

INTRODUCTION

Women living with HIV are vulnerable to gender-based violence (GBV) before and after diagnosis, in multiple settings. This study's aim was to explore how GBV is experienced by women living with HIV, how this affects women's sexual and reproductive health (SRH) and human rights (HR), and the implications for policymakers.

METHODS

A community-based, participatory, user-led, mixed-methods study was conducted, with women living with HIV from key affected populations. Simple descriptive frequencies were used for quantitative data. Thematic coding of open qualitative responses was performed and validated with key respondents.

RESULTS

In total, 945 women living with HIV from 94 countries participated in the study. Eighty-nine percent of 480 respondents to an optional section on GBV reported having experienced or feared violence, either before, since and/or because of their HIV diagnosis. GBV reporting was higher after HIV diagnosis (intimate partner, family/neighbours, community and health settings). Women described a complex and iterative relationship between GBV and HIV occurring throughout their lives, including breaches of confidentiality and lack of SRH choice in healthcare settings, forced/coerced treatments, HR abuses, moralistic and judgemental attitudes (including towards women from key populations), and fear of losing child custody. Respondents recommended healthcare practitioners and policymakers address stigma and discrimination, training, awareness-raising, and HR abuses in healthcare settings.

CONCLUSIONS

Respondents reported increased GBV with partners and in families, communities and healthcare settings after their HIV diagnosis and across the life-cycle. Measures of GBV must be sought and monitored, particularly within healthcare settings that should be safe. Respondents offered policymakers a comprehensive range of recommendations to achieve their SRH and HR goals. Global guidance documents and policies are more likely to succeed for the end-users if lived experiences are used.

Intimate partner violence and engagement in HIV care and treatment among women: a systematic review and meta-analysis

OBJECTIVE

We aimed to estimate the odds of engagement in HIV care and treatment among HIV-positive women reporting intimate partner violence (IPV).

DESIGN

We systematically reviewed the literature on the association between IPV and engagement in care. Data sources included searches of electronic databases (PubMed, Web of Science, CINAHL and PsychoInfo), hand searches and citation tracking.

METHODS

Two reviewers screened 757 full-text articles, extracted data and independently appraised study quality. Included studies were peer-reviewed and assessed IPV alongside engagement in care outcomes: antiretroviral treatment (ART) use; self-reported ART adherence; viral suppression; retention in HIV care. Odds ratios (ORs) were pooled using random effects meta-analysis.

RESULTS

Thirteen cross-sectional studies among HIV-positive women were included. Measurement of IPV varied, with most studies defining a 'case' as any history of physical and/or sexual IPV. Meta-analysis of five studies showed IPV to be significantly associated with lower ART use [OR 0.79, 95% confidence interval (95% CI) 0.64-0.97]. IPV was associated with poorer self-reported ART adherence in six studies (OR 0.48, 95% CI 0.30-0.75) and lower odds of viral load suppression in seven studies (OR 0.64, 95% CI 0.46-0.90). Lack of longitudinal data and measurement considerations should temper interpretation of these results.

CONCLUSION

IPV is associated with lower ART use, half the odds of self-reported ART adherence and significantly worsened viral suppression among women. To ensure the health of HIV-positive women, it is essential for clinical programmes to address conditions that impact engagement in care and treatment. IPV is one such condition, and its association with declines in ART use and adherence requires urgent attention.

HIV-Testing Rates and Testing Locations Among Women Who Have Experienced Intimate Partner Violence: Data From the Centers for Disease Control Behavioral Risk Factor Surveillance System, 2006

Data from the Centers for Disease Control and Prevention's (CDC) 2006 Behavioral Risk Factor Surveillance System were analyzed to report the HIV-testing rates and locations of women who have experienced intimate partner violence (IPV). Of the 18,917 women in the sample, 19.8% reported experiencing IPV. Over half of the women who experienced IPV reported testing rates of 52.4%, compared with 35.5% of the overall sample. Testing rates and locations significantly differed by race/ethnicity. Findings and their implications are explored, with an emphasis on increasing access to HIV testing and treatment for women who have experienced IPV and providing sexual safety planning for women accessing HIV-testing services.

Intimate partner violence, partner notification, and expedited partner therapy: a qualitative study

Over one-third of women experience intimate partner violence (IPV) in their lifetime. IPV increases the risk of infection and re-infection with sexually transmitted infections (STIs). The extent to which health care providers consider IPV when recommending partner notification and expedited partner therapy is unknown. The objective of this qualitative study was to understand health care providers' views on IPV and STIs when recommending partner treatment to patients with chlamydia. Using a purposive sampling strategy to include health care providers who treat young women at risk for chlamydia, 23 semi-structured, in-depth interviews were conducted. While some health care providers expressed concern for their patients' safety and believed assessing for IPV was needed before provision of expedited partner therapy, nearly a third had not considered the links between IPV and STIs. Strategies used by health care providers to assess for IPV did not include inquiry about specific behaviours related to IPV, STI risk, and sexual coercion. Many health care providers understand the risk for IPV in the setting of STI treatment, yet a significant portion of those interviewed failed to recognise the link between IPV and STIs. Provider education is necessary to increase knowledge and implement more effective inquiry and counselling about IPV to more safely recommend expedited partner therapy.

Substance-related coping, HIV-related factors, and mental health among an HIV-positive sexual minority community sample

HIV-positive status poses a unique set of social stressors, especially among lesbian, gay, and bisexual (LGB) persons. Among these difficulties are the internalization of HIV-related stigma and poor mental health. Unfortunately, substance use as a coping mechanism is also common, dependent on other demographic factors, among HIV-positive and LGB samples. The present study integrates these bodies of literature by examining main and interactive effects of HIV-related experiences (i.e., disclosure of HIV-positive status, fear of disclosure, HIV-related victimization, and internalized HIV-related stigma) and substance-related coping with discrimination as they impact mental health (i.e., stress, anxiety, depressive symptoms, and suicide and self-injury proneness). Participants were 216 HIV-positive LGB community members from an urban community medical clinic. Prominent results included: (1) robust negative effects of internalized HIV-related stigma on all mental health indicators when controlling for other HIV-related experiences and (2) a significant interaction in which substance-related coping significantly increases suicide proneness, only for those who have disclosed HIV-positive status to family or friends. Results are discussed with respect to theoretical perspectives of internalized stigma, implications for clinical work with LGB persons of HIV-positive status, and future research.

Intimate partner violence and communication of HIV diagnosis in Rakai, Uganda

Individuals who communicate their HIV diagnosis to sexual partners may be at increased risk of intimate partner violence (IPV). The authors examined past year self-reported IPV associated with communication of HIV diagnosis and other factors, in a sample of 679 sexually active; HIV-positive individuals age 18 to 49, who received HIV results and posttest counselling 12 months or more prior to the survey in Rakai, Uganda, using log-binomial multivariable regression. The rates of verbal and physical abuse among married individuals were significantly higher compared to unmarried persons, respectively. Physical abuse was significantly higher among women compared to men. IPV was not significantly associated with communication of HIV diagnosis. Interventions to prevent IPV among married HIV-positive individuals particularly women, at the community level, are needed.

Socioeconomic disadvantage increasing risk for depression among recently diagnosed HIV patients in an urban area in Brazil: cross-sectional study

Depression is the most common psychiatric co-morbidity among people living with HIV (PLHIV), with prevalence rates ranging from 25% to 36%. Depression impacts negatively upon adherence and response to combined antiretroviral therapy (CART) and the transmission of HIV infection through increased sexually risky behavior. This cross-sectional study presents data from a reference HIV-outpatient service in Dourados (Brazil) that evaluated the association between depressive symptoms, health-related quality of life, and clinical, socioeconomic, and demographic factors in newly diagnosed HIV/AIDS patients. Using the Beck Depression Inventory (BDI), the prevalence of depressive symptoms was 61% with a predominance of self-deprecating and cognitive-affective factors. Depressive symptoms were associated with lower income (p=0.019) and disadvantaged social class (p=0.005). Poorer quality of life was related to depressive symptoms (p<0.0001), low educational level (p=0.05), and lower income (p=0.03). These data suggest that socioeconomic factors, including level of income and education, are mediating the risk of depression and poor quality of life of PLHIV. Possible explanations for this effect are discussed, including the possible role of stigma.

Trauma history in African-American women living with HIV: effects on psychiatric symptom severity and religious coping

Women living with HIV (WLHIV) have rates of post-traumatic stress disorder (PTSD) up to 5 times higher than the general population. Individuals living with HIV and a concurrent diagnosis of PTSD have poorer HIV-related outcomes; however, the prevalence and impact of PTSD on African-American WLHIV seeking mental health treatment is unknown. The aim of this study is to examine the associations between PTSD symptoms with psychiatric symptom severity and psychological/religious coping strategies in African-American WLHIV who are seeking mental health treatment. This is a cross-sectional study of 235 African-American WLHIV attending an urban community mental health clinic. Bivariate analyses were conducted to evaluate associations between a PTSD symptoms scale (PSS≥21 versus PSS<21) and (1) psychiatric severity, (2) coping strategies, and (3) religious coping strategies. Thirty-six percent reported symptoms consistent with PTSD (PSS≥21). These women were significantly more likely to have worse mental health symptoms and were more likely to employ negative psychological and religious coping strategies. On the contrary, women with a PSS<21 reported relatively low levels of mental health symptoms and were more likely to rely on positive psychological and religious coping strategies. Over one-third of African-American WLHIV attending an outpatient mental health clinic had symptoms associated with PTSD. These symptoms were associated with worse mental health symptoms and utilization of dysfunctional religious and nonreligious coping strategies. Untreated PTSD in WLHIV predicts poorer HIV-related health outcomes and may negatively impact comorbid mental health outcomes. Screening for PTSD in WLHIV could identify a subset that would benefit from evidence-based PTSD-specific therapies in addition to mental health interventions already in place. PTSD-specific interventions for WLHIV with PTSD may improve outcomes, improve coping strategies, and allow for more effective treatment of comorbid mental health disorders.

The association between substance use and intimate partner violence within Black male same-sex relationships

Compared with the extant research on heterosexual intimate partner violence (IPV)-including the knowledge base on alcohol and illicit drug use as predictors of such IPV-there is a paucity of studies on IPV among men who have sex with men (MSM), especially Black MSM. This study investigates the prevalence of experiencing and perpetrating IPV among a sample of Black MSM couples and examines whether heavy drinking and/or illicit substance use is associated with IPV. We conducted a secondary analysis on a data set from 74 individuals (constituting 37 Black MSM couples) screened for inclusion in a couple-based HIV prevention pilot study targeting methamphetamine-involved couples. More than one third (n= 28, 38%) reported IPV at some point with the current partner: 24 both experiencing and perpetrating, 2 experiencing only, and 2 perpetrating only. IPV in the past 30 days was reported by 21 (28%) of the participants: 18 both experiencing and perpetrating, 1 experiencing only, and 2 perpetrating only. Heavy drinking and methamphetamine use each was associated significantly with experiencing and perpetrating IPV throughout the relationship as well as in the past 30 days. Rock/crack cocaine use was significantly associated with any history of experiencing and perpetrating IPV. Altogether, IPV rates in this sample of Black MSM couples equal or exceed those observed among women victimized by male partners as well as the general population of MSM. This exploratory study points to a critical need for further efforts to understand and address IPV among Black MSM. Similar to heterosexual IPV, results point to alcohol and illicit drug use treatment as important avenues to improve the health and social well-being of Black MSM.

Bidirectional links between HIV and intimate partner violence in pregnancy: implications for prevention of mother-to-child transmission

Introduction

Prevention of mother-to-child transmission (PMTCT) has the potential to eliminate new HIV infections among infants. Yet in many parts of sub-Saharan Africa, PMTCT coverage remains low, leading to unacceptably high rates of morbidity among mothers and new infections among infants. Intimate partner violence (IPV) may be a structural driver of poor PMTCT uptake, but has received little attention in the literature to date.

Methods

We conducted qualitative research in three Johannesburg antenatal clinics to understand the links between IPV and HIV-related health of pregnant women. We held focus group discussions with pregnant women (n=13) alongside qualitative interviews with health care providers (n=10), district health managers (n=10) and pregnant abused women (n=5). Data were analysed in Nvivo10 using a team-based approach to thematic coding.

Findings

We found qualitative evidence of strong bidirectional links between IPV and HIV among pregnant women. HIV diagnosis during pregnancy, and subsequent partner disclosure, were noted as a common trigger of IPV. Disclosure leads to violence because it causes relationship conflict, usually related to perceived infidelity and the notion that women are “bringing” the disease into the relationship. IPV worsened HIV-related health through poor PMTCT adherence, since taking medication or accessing health services might unintentionally alert male partners of the women's HIV status. IPV also impacted on HIV-related health via mental health, as women described feeling depressed and anxious due to the violence. IPV led to secondary HIV risk as women experienced forced sex, often with little power to negotiate condom use. Pregnant women described staying silent about condom negotiation in order to stay physically safe during pregnancy.

Conclusions

IPV is a crucial issue in the lives of pregnant women and has bidirectional links with HIV-related health. IPV may worsen access to PMTCT and secondary prevention behaviours, thereby posing a risk of secondary transmission. IPV should be urgently addressed in antenatal care settings to improve uptake of PMTCT and ensure that goals of maternal and child health are met in sub-Saharan African settings.

An expressive therapy group disclosure intervention for women living with HIV improves social support, self-efficacy, and the safety and quality of relationships: a qualitative analysis

Women living with HIV (WLHIV) face high rates of morbidity and mortality. HIV disclosure interventions have been identified as a promising but under-evaluated approach for WLHIV to improve their health and well-being. The Medea Project is an expressive therapy group intervention that was first developed to help incarcerated women develop the confidence and skills to tell their stories publicly in theatrical performances. The intervention was subsequently adapted as a community-based disclosure intervention for WLHIV. Our study describes an analysis of the impact of the Medea Project on the lives of the WLHIV who participated. All participating WLHIV publicly disclosed their HIV status during the performances. Five impact themes emerged from the data: sisterhood, catharsis, self-acceptance, safer and healthier relationships, and gaining a voice. Our study identifies a voluntary, effective, and broadly beneficial disclosure intervention for women living with HIV.

Violence, condom breakage, and HIV infection among female sex workers in Benin, West Africa

OBJECTIVE

To examine the relationship between violence, condom breakage, and HIV prevalence among female sex workers (FSWs).

METHODS

Data were obtained from the 2012 cross-sectional integrated biological and behavioral survey conducted in Benin. Multivariable log-binomial regression was used to estimate the adjusted prevalence ratios of HIV infection and condom breakage in relation to violence toward FSWs. A score was created to examine the relationship between the number of violence types reported and HIV infection.

RESULTS

Among the 981 women who provided a blood sample, HIV prevalence was 20.4%. During the last month, 17.2%, 13.5%, and 33.5% of them had experienced physical, sexual, and psychological violence, respectively. In addition, 15.9% reported at least 1 condom breakage during the previous week. There was a significant association between all types of violence and HIV prevalence. The adjusted prevalence ratios of HIV were 1.45 (95% confidence interval [95% CI], 1.05-2.00), 1.42 (95% CI, 1.02-1.98), and 1.41 (95% CI, 1.08-1.41) among those who had ever experienced physical, sexual, and psychological violence, respectively. HIV prevalence increased with the violence score (P = 0.002, test for trend), and physical and sexual violence were independently associated with condom breakage (P = 0.010 and P = 0.003, respectively).

CONCLUSIONS

The results show that violence is associated with a higher HIV prevalence among FSWs and that condom breakage is a potential mediator for this association. Longitudinal studies designed to analyze this relationship and specific interventions integrated to current HIV prevention strategies are needed to reduce the burden of violence among FSWs.

The clinical implications of high rates of intimate partner violence against HIV-positive women

INTRODUCTION

Intimate partner violence (IPV) is associated with increased risk of HIV infection among women, however, whether IPV affects outcomes after HIV infection is uncertain. We assess the impact of IPV on HIV-positive women.

METHODS

All HIV-positive women who received outpatient HIV care in southern Alberta between March 2009 and January 2012 were screened for IPV. The associations with IPV of sociodemographic factors, health-related quality of life, clinical status, and hospitalizations were obtained from a regional database and evaluated with multivariable regression analysis.

RESULTS

Of 339 women screened, 137 (40.4%) reported experiencing IPV. Those disclosing IPV had higher rates of smoking [adjusted prevalence ratio (APR) = 5.07; 95% confidence interval (CI): 2.72 to 9.43]; illicit drug use (APR = 7.58; CI: 2.45 to 23.26); a history of incarceration (APR = 4.84, CI: 1.85 to 12.68); depression (APR = 2.50, CI: 1.15 to 5.46); and anxiety disorders (APR = 5.75, CI: 2.10 to 15.63). Health-related quality of life was diminished with IPV (APR = 2.94, CI: 1.40 to 6.16) for poor/fair versus very good/excellent. IPV-exposed women were hospitalized 256 times per 1000 patient-years compared to 166/1000 patient-years among IPV-unexposed (P < 0.001) women. The relative risk was increased for HIV-unrelated hospitalizations (APR = 1.42, CI: 1.16 to 1.73) and for HIV-related hospitalizations after outpatient HIV care was initiated (APR = 2.19, CI: 1.01 to 4.85). Modifiable contributors to the poor outcomes included decreased use of antiretroviral therapy (APR = 0.55, CI: 0.34 to 0.91) and additional interruptions in care longer than 1 year (APR = 1.90, CI: 1.07 to 3.39).

CONCLUSIONS

IPV is associated with deleterious HIV-related and HIV-unrelated health outcomes, of which, suboptimal engagement in care is a contributor. To improve outcomes, practitioners should aim to increase engagement in care of these women in particular.

High rates of lifetime and recent violence observed among harder-to-reach women living with HIV

This study examined the prevalence and correlates associated with lifetime and recent violence among a sample of harder-to-reach human immunodeficiency virus (HIV)-positive women living in British Columbia (BC), Canada. Interviewer-led surveys with 1000 participants gathered quantitative data on social, economic, and structural characteristics such as housing status, relationship status, family structure, history of drug use, and sexual behavior. Logistic regression analysis modeled associations between independent variables and experiences of violence at baseline. Cox regression analyses with time-dependent covariates determined correlates of lifetime and recent violence among HIV-positive women. Of the 249 women in the study, an overwhelming proportion of women (81%) reported experiences of violence in their lifetime. Among those, 22% reported recent experiences of violence, and 56% of the women reported more than five violent episodes in their lifetime. Lifetime violence was independently associated with HIV-related stigma (adjusted odds ratio [AOR] = 2.18, 95% confidence interval [CI] = 1.14-5.70), previous tobacco use (AOR = 2.79, 95% CI = 1.10-7.07), ever having a drinking problem (AOR = 2.82, 95% CI = 1.28-6.23), and ever having received care for a mental health condition (AOR = 2.42, 95% CI = 1.06-5.52). Recent violence was associated with the current illicit drug use (AOR = 2.60, 95% CI = 1.14-5.90), and currently residing in unstable housing (AOR = 2.75, 95% CI = 1.31-5.78). This study underscores the need to consider potential experiences of historical and current violence as part of comprehensive care for women living with HIV.

The syndemic effects of intimate partner violence, HIV/AIDS, and substance abuse on depression among low-income urban women

Intimate partner violence (IPV), HIV/AIDS, and substance use are epidemics among low-income urban women that have been described together as the "SAVA syndemic" because of their co-occurring nature. This study examines the synergistic or "syndemic" effect of these three health issues on depression among urban women and evaluates social support as a protective factor that might reduce depressive symptoms associated with the Substance Abuse, Violence, and AIDS (SAVA) syndemic. Data from 445 urban women were collected through in-person interviews. All women were over the age of 18, not pregnant, English speaking, and reported having a main partner in the past year. Twenty-five percent had experienced all three factors of the SAVA syndemic (were HIV-positive, had experienced IPV in the past year, and had used cocaine or heroin in their lifetime). HIV-positive status, hard drug use, IPV, and low levels of social support were all individually associated with greater depressive symptoms. When controlling for demographics and other SAVA factors, IPV and hard drug use in the past 30 days remained associated with depressive symptoms, as did low social support. However, social support did not modify the effect of the SAVA factors on depression. Compared to women who experienced no SAVA factors, women who had experienced all three factors were 6.77 times more likely to have depressive symptoms. These findings confirm that IPV is significantly associated with depressive symptoms and that the syndemic impact of IPV, substance use, and HIV could have even more extreme effects on depression outcomes.

A systematic review of the frequency and correlates of partner abuse in HIV-infected women and men who partner with men

Partner abuse (PA) is a highly prevalent and devastating social phenomenon, extracting an economic toll of more than $8 billion annually in the United States due to lost productivity alone. Many of the risk factors for PA increase vulnerability to acquiring HIV as well, yet little research has explored these overlapping epidemics. In this systematic review, we examine the frequency of PA victimization from male partners among persons living with HIV-both men who have sex with men (MSM) and women. We located 31 manuscripts reporting data from 24 unique samples, indicating a high lifetime frequency (but large range) of estimates for women/MSM, respectively, for physical (26-62%/15-39%), sexual (22-44%/8-33%), and psychological abuse (55%/22-73%). Data indicate strong and consistent associations of PA with poor mental health, engagement in health risk behaviors, and nonadherence to HIV medication for both groups. We discuss implications for clinical practice as well as future research directions.

Does HIV increase the risk of spousal violence in sub-Saharan Africa?

Although a positive association is found between HIV prevalence and intimate partner violence, a causal interpretation is hard to establish due to the endogeneity of HIV prevalence. Using the distance from the origin of the virus as an instrument, I find that an exogenous increase in HIV prevalence in a cluster has a sizable positive effect on the risk of physical and sexual violence against women within marriage. The results of this study confirm a gender-specific negative externality of the disease and encourage policy efforts to incorporate services for violence against women into existing HIV programs.

Sometimes you just have to have a lot of bitter to make it sweet: Substance abuse and partner abuse in the lives of HIV+ men who have sex with men

Although links between partner abuse (PA) and substance abuse (SA) are well-documented in the literature, we know less about these relations among HIV-positive men who have sex with men (MSM). We conducted a qualitative study with this group (N = 28). Participants reported (1) social modeling of SA in childhood and in adult social networks, (2) initial use of substance to cope with child abuse and neglect, and (3) the reinforcement of problematic SA by experiences of PA, whereby SA led to PA, resulting in increased SA. Recommendations for clinicians working with HIV+ MSM are discussed.

Sexual risk behaviors by relationship type and trauma history among HIV-positive men who have sex with men

The association of trauma exposure and coping style to sexual risk behavior has yet to be fully examined in the context of primary and casual sexual partnerships. The current study assessed a high risk sexual behavior-unprotected anal intercourse (UAI)-in a high risk population of HIV-positive men who have sex with men (MSM) with a history of trauma. Using audio computer-assisted self-interview technology, 132 HIV-positive MSM completed measures of trauma exposure, trauma symptoms, coping strategies, and sexual risk behavior. Hierarchical logistic regression analyses indicated that completing more years of education and having experienced sexual abuse were positively associated with UAI with casual partners. Additionally, use of active coping was negatively associated with UAI with casual partners and the final model significantly predicted variance in UAI with casual partners. However, no variables were significantly associated with UAI with primary partners, suggesting that sexual risk behavior with primary partners may be associated with factors not commonly assessed in risk prediction or prevention research. We discuss the results in the context of developing new or modifying existing interventions to address rates of sexual risk in the relationships of HIV-positive MSM.

Access to HIV prevention services among gender based violence survivors in Tanzania

INTRODUCTION

Currently, Tanzania's HIV prevalence is 5.7%. Gender inequality and Gender Based Violence (GBV) are among factors fuelling the spread of HIV in Tanzania. This study was conducted to assess universal access to HIV prevention services among GBV survivors in Iringa and Dar-es-Salaam where HIV prevalence is as high as 14.7% and 9% respectively compared to a national average of 5.7%.

METHODS

In 2010, a mixed methods study using triangulation model was conducted in Iringa and Dar-es-Salaam regions to represent rural and urban settings respectively. Questionnaires were administered to 283 randomly selected survivors and 37 health providers while 28 in-depth interviews and 16 focus group discussions were conducted among various stakeholders. Quantitative data was analyzed in SPSS by comparing descriptive statistics while qualitative data was analyzed using thematic framework approach.

RESULTS

Counseling and testing was the most common type of HIV prevention services received by GBV survivors (29%). Obstacles for HIV prevention among GBV survivors included: stigma, male dominance culture and fear of marital separation. Bribery in service delivery points, lack of confidentiality, inadequate GBV knowledge among health providers, and fear of being involved in legal matters were mentioned to be additional obstacles to service accessibility by survivors. Reported consequences of GBV included: psychological problems, physical trauma, chronic illness, HIV infection.

CONCLUSION

GBV related stigma and cultural norms are obstacles to HIV services accessibility. Initiation of friendly health services, integration of GBV into HIV services and community based interventions addressing GBV related stigma and cultural norms are recommended.

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

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

Investigating partner abuse among HIV-positive men who have sex with men

High rates of partner abuse (PA) of all types-physical, sexual, and psychological-have been identified in studies of HIV-positive individuals. We examined both the prevalence and correlates of same-sex PA in HIV-positive men who have sex with men (MSM). Participants recruited from public outpatient HIV clinics (N = 168) completed CASI surveys about PA and current physical and mental health. Electronic medical record data were obtained for HIV biomarkers. Results indicate high rates of past year PA (physical, 19%; sexual, 17%; psychological, 51%; any, 54%), with rates comparable to, or higher than, those reported in recent studies of HIV-positive women and older studies of HIV-positive MSM. Overall, participants endorsing past year PA reported poorer mental but not physical health. Participants who endorsed past year physical PA, specifically, reported the largest number of mental health problems. HIV care providers should routinely assess PA, especially physical PA, in all MSM patients.