Perceived Stigma as a Contextual Barrier to Early Uptake of HIV Testing, Treatment Initiation, and Disclosure; the Case of Patients Admitted with AIDS-Related Illness in a Rural Hospital in South Africa

"When selling anything to an audience, visible publicity is key:" experiences, barriers, and enablers to participate in a COVID-19 study in Malawi

BACKGROUND

Many studies in infectious diseases struggle to recruit participants. The SARS-CoV-2 infection, transmission dynamics, and household impact in Malawi (SCATHIM) study reported a refusal rate of 57.2%. Adequate publicity can lead to more people participating in studies. This study explored the reasons for participating in the SCATHIM study.

METHODS

A descriptive qualitative study informed by the theory of reasoned action was conducted in Blantyre between January 2022 and March 2022 to assess factors that influence participation in a COVID-19 study among 10 index cases, 10 caregivers, 10 study decliners, and 5 research staff. The data were collected via in-depth interview guides, audio recorded, transcribed, managed via NVIVO and analysed via a thematic approach.

RESULTS

The factors that motivated participation in the study included one's knowledge of COVID-19; potential access to medical services, including free COVID-19 tests for members of the household; financial reimbursements; and the ability to contribute scientific knowledge. The barriers to participation included minimal publicity of the study amidst a novel condition, perceived stigma and discrimination, perceived invasion of privacy, discomfort with the testing procedures, and suboptimal financial reimbursements.

CONCLUSION

Effective publicity and outreach strategies have the potential to decrease refusal rates in study participation, especially if a condition is novel. Studies on infectious diseases should address stigma and discrimination to promote participation and ensure participant safety.

"If you find that I am HIV positive, don't tell me": Exploring the barriers and recommendations for HIV prevention services utilization among youth in rural southwestern Uganda

Globally, the majority of new HIV infections are recorded in Eastern and Southern Africa, with the youth being disproportionately affected. HIV prevention is the cornerstone of controlling the spread of HIV and ending this epidemic by 2030. However, barriers to the utilization of HIV prevention services remained underexplored especially among the youth in rural settings in sub-Saharan Africa. This qualitative study, conducted between February and April 2022 in rural southwestern Uganda, explored these barriers and identified recommendations to improve the utilization of HIV prevention services among youth. We conducted six focus group discussions (with youth [15-24 years] both in and out of school), nine in-depth interviews (with teachers, health workers, and members of the village health team), and four key informant interviews (with district officials) to collect data. Thematic analysis revealed barriers at the individual level (e.g., misconceptions, fear of testing, low perceived HIV risk, confidentiality concerns), community level (e.g., stigma, lack of counseling, peer influence), and health system level (e.g., lack of youth-friendly services). Recommendations included formation of youth peer support groups, ongoing awareness campaigns, and socio-economic empowerment initiatives, particularly targeting adolescent girls and young women. National scaling of these initiatives is essential to overcoming identified barriers and reducing HIV transmission among this vulnerable population. Additionally, economic empowerment especially among adolescent girls and young women in rural areas has enormous potential to address the spread of HIV in this sub-population.

Changes in Stigma and Social Support among Participants in a Randomized Trial of a Novel Expanded Social Network-based HIV Testing Intervention in KwaZulu-Natal, South Africa

HIV-related stigma is a well-documented barrier to HIV testing in South Africa, and may be particularly likely to create reluctance to test among South African men, who have reported feeling blamed for HIV by their partners and communities. The present study presents a novel expanded social network recruitment to HIV testing (E-SNRHT) intervention explicitly designed to reduce stigma as a barrier to testing by asking people to recruit anyone they know to testing, thus allowing them to avoid the potential for increased stigma and/or blame associated with direct risk partner recruitment, and helping to normalize openly discussing HIV among social networks. We examined baseline and 6-10-week follow-up data from a 2022-2023 randomized trial in KwaZulu-Natal, South Africa that recruited 110 individuals who had been newly diagnosed with HIV and randomly assigned them to recruit people to HIV testing either via the E-SNRHT intervention or via risk network recruitment. Participants in the E-SNRHT intervention reported significant decreases in anticipated and enacted HIV-related stigma between baseline and follow-up; and the E-SNRHT intervention was more effective at decreasing enacted HIV-related stigma than was risk network recruitment. Individuals newly diagnosed with HIV by the E-SNRHT intervention reported significant increases in social support between intervention enrollment and follow-up, and all of these individuals reported participating in positive conversations about HIV services with peers in the 6-10 weeks after intervention enrollment. These findings suggest that E-SNRHT is a potentially important strategy to reduce HIV-related stigma as a barrier to HIV testing among peer networks in KwaZulu-Natal.

A mixed methods process evaluation: understanding the implementation and delivery of HIV prevention services integrated within sexual reproductive health (SRH) with or without peer support amongst adolescents and young adults in rural KwaZulu-Natal, South Africa

BACKGROUND

Combination prevention interventions, when integrated with community-based support, have been shown to be particularly beneficial to adolescent and young peoples' sexual and reproductive health. Between 2020 and 2022, the Africa Health Research Institute in rural South Africa conducted a 2 × 2 randomised factorial trial among young people aged 16-29 years old (Isisekelo Sempilo) to evaluate whether integrated HIV and sexual and reproductive health (HIV/SRH) with or without peer support will optimise delivery of HIV prevention and care. Using mixed methods, we conducted a process evaluation to provide insights to and describe the implementation of a community-based peer-led HIV care and prevention intervention targeting adolescents and young people.

METHODS

The process evaluation was conducted in accordance with the Medical Research Council guidelines using quantitative and qualitative approaches. Self-completed surveys and clinic and programmatic data were used to quantify the uptake of each component of the intervention and to understand intervention fidelity and reach. In-depth individual interviews were used to understand intervention experiences. Baseline sociodemographic factors were summarised for each trial arm, and proportions of participants who accepted and actively engaged in various components of the intervention as well as those who successfully linked to care were calculated. Qualitative data were thematically analysed.

RESULTS

The intervention was feasible and acceptable to young people and intervention implementing teams. In particular, the STI testing and SRH components of the intervention were popular. The main challenges with the peer support implementation were due to fidelity, mainly because of the COVID-19 pandemic. The study found that it was important to incorporate familial support into interventions for young people's sexual health. Moreover, it was found that psychological and social support was an essential component to combination HIV prevention packages for young people.

CONCLUSION

The results demonstrated that peer-led community-based care that integrates SRH services with HIV is a versatile model to decentralise health and social care. The family could be a platform to target restrictive gender and sexual norms, by challenging not only attitudes and behaviours related to gender among young people but also the gendered structures that surround them.

Adapting a health facility HIV stigma-reduction participatory training intervention to address drug use stigma in HIV care and treatment clinics in Dar es Salaam, Tanzania

BACKGROUND

HIV prevalence among people who use drugs (PWUD) in Tanzania is 4-7 times higher than in the general population, underscoring an urgent need to increase HIV testing and treatment among PWUD. Drug use stigma within HIV clinics is a barrier to HIV treatment for PWUD, yet few interventions to address HIV-clinic drug use stigma exist. Guided by the ADAPT-ITT model, we adapted the participatory training curriculum of the evidence-based Health Policy Plus Total Facility Approach to HIV stigma reduction, to address drug use stigma in HIV care and treatment clinics (CTCs).

METHODS

The first step in the training curriculum adaptation process was formative research. We conducted 32 in-depth interviews in Dar es Salaam, Tanzania: 18 (11 men and 7 women) with PWUD living with HIV, and 14 with a mix of clinical [7] and non-clinical [7] CTC staff (5 men and 9 women). Data were analyzed through rapid qualitative analysis to inform initial curriculum adaptation. This initial draft curriculum was then further adapted and refined through multiple iterative steps of review, feedback and revision including a 2-day stakeholder workshop and external expert review.

RESULTS

Four CTC drug use stigma drivers emerged as key to address in the curriculum adaptation: (1) Lack of awareness of the manifestations and consequences of drug use stigma in CTCs (e.g., name calling, ignoring PWUD and denial of care); (2) Negative stereotypes (e.g., all PWUD are thieves, dangerous); (3) Fear of providing services to PWUD, and; (4) Lack of knowledge about drug use as a medical condition and absence of skills to care for PWUD. Five, 2.5-hour participatory training sessions were developed with topics focused on creating awareness of stigma and its consequences, understanding and addressing stereotypes and fears of interacting with PWUD; understanding drug use, addiction, and co-occurring conditions; deepening understanding of drug use stigma and creating empathy, including a panel session with people who had used drugs; and working to create actionable change.

CONCLUSION

Understanding context specific drivers and manifestations of drug use stigma from the perspective of PWUD and health workers allowed for ready adaptation of an existing evidence-based HIV-stigma reduction intervention to address drug use stigma in HIV care and treatment clinics. Future steps include a pilot test of the adapted intervention.

The relationship between HIV-related stigma and quality of life among HIV infected outpatients: A cross-sectional study in Vietnam

Background

The impact of stigma on individuals with HIV remains a significant challenge, causing feelings of worthlessness, shame, and emotional distress. This study aimed to examine the relationship between HIV-related stigma and quality of life (QOL) among HIV-infected outpatients initiating antiretroviral therapy (ART) in Vietnam.

Design and methods

This was a cross-sectional study which conducted at Vinh General Hospital, Nghe An Province, involved 323 HIV-infected outpatients. Participants were surveyed between October 2020 and October 2021. The study collected data through structured interviews, assessing socio-demographic factors, HIV stigma, and QOL.

Results

The result showed that HIV-infected outpatients experiencing higher stigma showed poorer QOL across various domains. The negative impact of stigma was particularly evident in domains related to physical health, psychological well-being, and spirituality. Participants who were married, had children, consumed alcohol, had comorbidities (particularly hepatitis B/C), and lacked a history of drug use reported varying levels of correlation with QOL domains and stigma.

Conclusions

By identifying the intricate connections between stigma and QOL, the study provides valuable insights for designing comprehensive interventions that prioritize the well-being of HIV infected outpatients.

Understanding HIV service preferences of South African women 30-49 years old missing from or linked to care: An exploratory study of Gauteng and Limpopo provinces

BACKGROUND

The HIV epidemic in sub-Saharan Africa has a disproportionate gender impact, with women bearing the brunt of the epidemic. South Africa carries the largest share of the global HIV burden, with similar trends seen for women due to unequal socio-cultural and economic status.

OBJECTIVES

This study aims to understand 30-49 year-old women's barriers and facilitators to accessing HIV services in order to maximize health in resource limited settings and reach women missing from HIV care.

DESIGN

Employing a convenience sampling strategy, we recruited, informed, and consented participants at clinics and public areas. Interviews were conducted in respondent's preferred languages, transcribed verbatim, translated into English if needed, and thematically analyzed using grounded theory.

METHODS

We conducted 81 interviews with women aged 30-49 either missing from care (n = 21), having unknown HIV status (n = 30) or linked to care (n = 30) within two sites: City of Johannesburg district, Gauteng Province and Mopani district, Limpopo Province.

RESULTS

Participants missing from care reported negative staff attitudes, queues, family rejection, medication side effects, and painful blood tests as key deterrents. Participants with an unknown status were deterred by fear of being diagnosed as HIV positive and family rejection, which was similar to women missing from care who often dropped out from care due to actual family rejection. Participants linked to care reported that long queues and staff shortages were challenges but stayed in care due to a will to live for themselves and their children, in addition to counselling and feeling emotionally supported. Interestingly, participants missing from care often accessed medication from friends but, similarly to those with unknown status, noted that they would access care if attended to by supportive nurses and by having non-clinical HIV services.

CONCLUSIONS

The accounts of women in this research highlight significant improvements needed to address inequities in the fight against HIV in South Africa. Additionally, the healthcare service access preferences of women aged 30-49 need to be further explored quantitatively in order to design policy relevant interventions.

Shame and stigma in association with the HCV cascade to cure among people who inject drugs

BACKGROUND

Psycho-social experiences including shame and experienced and internalized stigma have been associated with substance use, HCV infection, and reluctance to disclose HCV status and pursue treatment. These psycho-social barriers have been examined independently for many chronic diseases, including HCV, but to our knowledge have not been quantitatively explored in a large multi-site US-based sample of people who inject drugs (PWID) in HCV treatment.

METHODS

We examine baseline relationships with HCV-stigma and engagement across the HCV treatment cascade as well as baseline and longitudinal relationships between shame and engagement across the HCV treatment cascade including treatment initiation, adherence, completion, and sustained virologic response (SVR) among a multi-site sample of PWID with HCV, where N=755 were randomized to the pragmatic trial comparing HCV treatment outcomes in modified directly observed treatment (mDOT) or patient navigation, and N=623 initiated treatment.

RESULTS

While cross-sectional assessments of shame and HCV-stigma were not associated with engagement across the HCV treatment cascade, those whose shame scores decreased compared to those who reported consistently high and increasing levels of shame were significantly more likely to complete HCV treatment (aOR=5.29; 95%CI: 1.56,18.00) and achieve SVR (aOR=6.32; 95%CI: 1.61, 24.87).

CONCLUSION

Results underscore the relationships between lower levels of shame and health-related behavior and treatment outcomes among PWID and suggest SVR achievement may contribute to reductions in shame or that reductions in shame may contribute to continued treatment and thus SVR.

Interventions to improve young men's utilisation of HIV-testing services in KwaZulu-Natal, South Africa: perspectives of young men and health care providers

Introduction: HIV-testing services (HTS) are an important point of entry to prevention and treatment of HIV in South Africa. Despite the availability of HTS across the region and in SA, the uptake among men remains low, especially young men residing in rural and peri-urban communities. This study aimed to explore interventions that could improve the uptake of HTS among young men in KwaZulu-Natal.Methods: A descriptive exploratory qualitative study was conducted in which 17 young men and two health care providers in Ladysmith were purposively and conveniently sampled. Data were collected through semi-structured interviews using WhatsApp and landline audio calls between September and December 2021 and thematically analysed.Results: An improvement in the health care provider attitudes and service delivery, establishment of adherence clubs for young people living with HIV, ensuring a diverse and balanced health care provider staff composition at primary health care facilities, and increased demand creation in spaces frequented by men are vital for enhancing access and utilisation of HTS among young men. Additionally, health care providers believe that the presence of male health care providers, investment in health education, prioritising men in the morning at the primary health care facilities, and the establishment of male clinics within communities as key factors in improving the uptake of HTS among young men.Conclusion: To attract and retain young men in HTS and in HIV treatment and care, several improvements at primary health care facilities need to be implemented. These should focus on addressing the specific needs and preferences of young men, ensuring their comfort and engagement in health care.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

HIV Late Presenters in Asia: Management and Public Health Challenges

Many individuals are diagnosed with human immunodeficiency virus (HIV) infection at an advanced stage of illness and are considered late presenters. We define late presentation as a CD4 cell count below 350 cells/mm³ at the time of HIV diagnosis, or presenting with an AIDS-defining illness regardless of CD4 count. Across Asia, an estimated 34-72% of people diagnosed with HIV are late presenters. HIV late presenters generally have a higher disease burden and higher comorbidity such as opportunistic infections than those who are diagnosed earlier. They also have a higher mortality rate and generally exhibit poorer immune recovery following combined antiretroviral therapy (cART). As such, late HIV presentation leads to increased resource burden and costs to healthcare systems. HIV late presentation also poses an increased risk of community transmission since the transmission rate from people unaware of their HIV status is approximately 3.5 times higher than that of early presenters. There are several factors which contribute to HIV late presentation. Fear of stigmatisation and discrimination are significant barriers to both testing and accessing treatment. A lack of perceived risk and a lack of knowledge by individuals also contribute to late presentation. Lack of referral for testing by healthcare providers is another identified barrier in China and may extend to other regions across Asia. Effective strategies are still needed to reduce the incidence of late presentation across Asia. Key areas of focus should be increasing community awareness of the risk of HIV, reducing stigma and discrimination in testing, and educating healthcare professionals on the need for early testing and on the most effective ways to engage with people living with HIV. Recent initiatives such as intensified patient adherence support programs and HIV self-testing also have the potential to improve access to testing and reduce late diagnosis.

Acceptability and usability of a paediatric HIV screening tool in high-volume outpatient settings in Malawi, perspectives from caregivers and healthcare workers

BACKGROUND

Using an HIV pretest screening tool to identify children most at risk for HIV infection may be a more efficient and cost-effective approach to identify children living with HIV in resource-limited settings. These tools seek to reduce overtesting of children by increasing the positive predictive value while ensuring a high negative predictive value for those screened for HIV.

METHODS

This qualitative study in Malawi evaluated acceptability and usability of a modified version of the Zimbabwe HIV screening tool to identify children aged 2-14 years most-at-risk. The tool included additional questions about previous hospitalisations due to malaria and prior documented diagnoses. Sixteen interviews were conducted with expert clients (ECs), trained peer-supporters, which administered the screening tool and 12 interviews with biological and non-biological caregivers of screened children. All interviews were audiorecorded, transcribed and translated. Transcripts were analysed manually using a short-answer analysis, compiling responses for each question by study participant group. Summary documents were generated, identifying common and outlier perspectives.

RESULTS

The HIV paediatric screening tool was generally accepted by caregivers and ECs, with both groups seeing the benefit of the tool and promoting its use. The ECs who were primarily responsible for implementing the tool initially struggled with acceptance of the tool but started to accept it after additional training and mentorship was provided. Overall, caregivers accepted having their children tested for HIV, although non-biological caregivers expressed hesitancy in giving consent for HIV testing. ECs reported challenges with the ability for non-biological caregivers to answer some questions.

CONCLUSION

This study found general acceptance of paediatric screening tools in children in Malawi and identified some minor challenges that raise important considerations for tool implementation. These include the need for a thorough orientation of the tools for the healthcare workers and caregivers, appropriate space at the facility, and adequate staffing and commodities.

Stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among general adult population: the results from the 6th Thai National Health Examination Survey (NHES VI)

Background

Thailand has an ongoing action plan to reduce human immunodeficiency virus (HIV) discrimination and stigma. We aimed to monitor the level of stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among the general adult population and to investigate its related factors.

Methods

This study was based on data from the 6^th Thai National Health Examination Survey, a large-scale country-wide survey in 2019-2020. We used a multistage sampling technique and included 11 843 adults aged 20 to 59. We collected data through face-to-face interviews which included six items related to HIV stigma domains. We weighted all analyses to account for the probability of sampling the Thai population aged 20 to 59 years.

Results

We found that anticipated stigma had the highest percentage of negative stigmatizing attitude responses (78.5%), followed by perceived stigma (66.6%), fear of HIV infection (54.4%), and social judgment (28.2%). Regarding the UNAIDS global indicator for discriminatory attitude, 48.6% of respondents had negative perceptions to questions about experienced stigma or discrimination. Multiple logistic regression showed that factors associated with discriminatory attitudes toward PLWHA were being aged 20-39 (adjusted odds ratio (aOR) = 1.32, 95% confidence interval (CI) = 1.18-1.47) or 50-59 (aOR = 1.23, 95% CI = 1.09-1.40) compared to being aged 40-49, being Muslim compared to Buddhist (aOR = 1.73, 95% CI = 1.46-2.06), being married compared to being single (aOR = 1.15, 95% CI = 1.04-1.28), holding certificate degree or higher compared to not studying or studying at a primary level (aOR = 0.81, 95% CI = 0.68-0.97), living in the Northeast (aOR = 1.27, 95% CI = 1.12-1.45) and Bangkok (aOR = 1.30, 95% CI = 1.12-1.51) compared to living in the North, having no HIV/AIDS infected relative or acquaintance compared to having an HIV/AIDS infected relative or acquaintance (aOR = 1.56, 95% CI = 1.41-1.73), and not obtaining an HIV test compared to obtaining it (aOR = 1.10, 95% CI = 1.02-1.19).

Conclusions

We found that HIV stigmatizing and discriminatory attitudes toward PLWHA decreased, but remained concerning among Thai adult people. A public education and awareness campaign, as well as an intervention to reduce HIV-related stigma and discrimination in the country's health care facilities, must still be maintained.

Healthcare seeking patterns for TB symptoms: Findings from the first national TB prevalence survey of South Africa, 2017-2019

BACKGROUND

Although tuberculosis (TB) symptoms have limited sensitivity they remain an important entry point into the TB care cascade.

OBJECTIVES

To investigate self-reported healthcare seeking for TB symptoms in participants in a community-based survey.

METHODS

We compared reasons for not seeking care in participants reporting ≥1 of four TB screening symptoms (cough, weight loss, night sweats, fever) in the first South African national TB prevalence survey (2017-2019). We used logistic regression analyses to identify sociodemographic and clinical characteristics associated with healthcare seeking.

RESULTS

5,168/35,191 (14.7%) survey participants reported TB symptoms and 3,442/5168 had not sought healthcare. 2,064/3,442(60.0%) participants intended to seek care, 912 (26.5%) regarded symptoms as benign, 399 (11.6%) reported access barriers(distance and cost), 36 (1.0%) took other medications and 20(0.6%) reported health system barriers. Of the 57/98 symptomatic participants diagnosed with bacteriologically confirmed TB who had not sought care: 38(66.7%) intended to do so, 8(14.0%) regarded symptoms as benign, and 6(10.5%) reported access barriers. Among these 98, those with unknown HIV status(OR 0.16 95% CI 0.03-0.82), p = 0.03 and those who smoked tobacco products(OR 0.39, 95% CI 0.17-0.89, p = 0.03) were significantly less likely to seek care.

CONCLUSIONS

People with TB symptoms delayed seeking healthcare, many regarded symptoms as benign while others faced access barriers. Those with unknown HIV status were significantly less likely to seek care. Strengthening community-based TB awareness and screening programmes together with self-screening models could increase awareness of the significance of TB symptoms and contribute to improving healthcare seeking and enable many people with TB to enter the TB care cascade.

HIV Disclosure Among Sexually Infected People Living with HIV and AIDS in China: Prevalence, Influencing Factors, and Negative Outcomes

HIV disclosure is crucial for HIV prevention and control, but may also lead to discrimination, insult, and even violence against people living with HIV and AIDS (PLWHAs). In this study, we examined HIV disclosure, its influencing factors, and its association with intimate partner violence (IPV) among 1153 PLWHAs through the sexual route in Jinan, Shandong Province, China. Our results showed that 76.4% (881/1153) PLWHAs had disclosed someone about their HIV infection, the HIV disclosure rates among family members, friends, spouses, and current fixed partners of PLWHAs were 43.5% (501/1153), 47.9% (552/1153), 56.8% (129/227), and 43.2% (336/777), respectively. HIV disclosure was affected by socio-demographics, disease characteristics, and psycho-social factors and varied among family members, close friends, spouses, and current fixed sexual partners. Age ≤ 33 years (aOR 1.79, 95% CI 1.27-2.53), heterosexual infection route (aOR 1.52, 95% CI 1.06-2.17), HIV diagnosis time > 36 months (aOR 1.84, 95% CI 1.30-2.59), with other chronic diseases (aOR 1.87, 95% CI 1.34-2.61), lower self-stigma (aOR 4.03-4.36, 95% CI 1.98-8.74), higher social support (aOR 1.71-1.73, 95% CI 1.03-2.83), no depression (aOR 1.54, 95% CI 1.12-2.11), and no suicidal ideation (aOR 1.79, 95% CI 1.28-2.50) were all independently associated with increased likelihood of HIV disclosure. HIV disclosure was associated with an increased risk of IPV among current fixed sexual partners (aOR 1.87, 95% CI 1.38-2.54) and spouses (aOR 2.54, 95% CI 1.41-4.56). Our findings suggest that the HIV disclosure rate of PLWHAs is still low and is affected by multiple factors. There is an urgent need to design targeted and comprehensive interventions to improve HIV disclosure. IPV prevention should also be incorporated into the intervention system of HIV disclosure to ensure adequate and continuous support for PLWHAs.

Analysis of intention and influencing factors on mobile information follow-up service in HIV/AIDS in a city in China

Objectives

This study aimed to evaluate the willingness of patients with HIV/AIDS in Henan province to accept mobile information follow-up, to find the key factors that affect behavioral willingness to accept such follow-up, to explore the internal mechanism of the mobile service, and to provide a theoretical rationale for the further promotion of mobile follow-up.

Methods

This study used the technology acceptance model (TAM) as its main theoretical tool, which adopted a stratified random sampling method, and investigated 284 patients with HIV/AIDS in area six of Sanmenxia City. An on-site questionnaire survey method was adopted for this study. Confirmatory factor analysis was used for structural validity, with Cronbach's coefficient used for reliability. Data analysis mainly used SPSS23.0 and AMOS23.0 software.

Results

The acceptance rate of the HIV/AIDS mobile follow-up service was 68.53%. In the study, product factors (PFs) were considered important in the indirect path of the TAM. Our TAM model suggested that high perceived usefulness (PU), perceived ease of use (PEU), and perceived innovativeness (PI) of the service were significant in improving mobile health (mHealth) acceptance among patients with HIV/AIDS in China. Subjective norms (SNs) also contributed to popularizing the service in the HIV/AIDS community. The model fitting was considered acceptable (root mean square error of approximation, RMSEA = 0.074; goodness of fit index, GFI = 0.905; comparative fit index, CFI = 0.963, and Tucker-Lewis index, TLI = 0.593).

Conclusion

PFs and SNs exerted an important influence on the behavioral intentions of the patients with HIV/AIDS who accepted mobile health. PU was another important factor affecting behavioral intention. The practicality of mHealth services was crucial. Convenience and the innovativeness of the experience with the service will be conducive to the promotion and use of mHealth follow-up services.

Psychosocial support for HIV serodiscordant couples

Introduction

South Africa has the largest HIV epidemic, with 8.2 million people living with the virus. It has a high HIV prevalence of 13.7% and 230,000 new infections in 2020. It is estimated that HIV serodiscordant couples contribute up to 60% of new HIV infections in sub-Saharan Africa. However, there have been no specific programmes/activities to deliberately cater for couples in HIV serodiscordant relationships. The purpose of this study was to examine the psychosocial support provided for HIV serodiscordant couples both in health care settings and in the community.

Methods

An interpretative phenomenological analysis (IPA) design was utilised for this study. In-depth interviews were conducted with thirteen HIV serodiscordant couples. Data collection was guided by an interview guide. All audio-recorded interview data were transcribed verbatim into written text. Data analysis was conducted using an interpretative phenomenological analysis framework. A third person-an expert in qualitative research, acted as an independent co-coder and conducted the open coding of each transcript.

Findings

The findings indicated that HIV serodiscordant couples received psychosocial support from their partners, family, and health care workers. This support was emotional, or in the form of counselling, reminders on taking medication, financial and household chores. The support provided by health care providers proved to be deficient and did not address the diverse needs of this group.

Conclusion

Psychosocial support plays a critical role in enhancing the quality of life of HIV serodiscordant couples. Therefore, client centred, and tailor-made interventions should be made available to this special with diverse needs group.

Viral suppression among pregnant adolescents and women living with HIV in rural KwaZulu-Natal, South Africa: a cross sectional study to assess progress towards UNAIDS indicators and Implications for HIV Epidemic Control

BACKGROUND

South Africa has made significant progress in scaling up antiretroviral therapy (ART) to achieve the aspirational goal of HIV epidemic control. The aim of this study was to determine the prevalence of HIV, assess progress towards each of the Joint United Nations Programme on HIV/AIDS (UNAIDS) indicators and determine factors associated with achieving viral suppression among pregnant adolescents and women living with HIV in rural KwaZulu-Natal, South Africa.

METHODS

Pregnant adolescents and women, 12 years and older seeking antenatal care at six primary health care clinics were enrolled in a cross-sectional study. Following written informed consent, structured questionnaires were administered, and finger-prick blood samples were collected for HIV antibody testing and viral load measurement. Viral suppression was defined as HIV viral load of < 400 copies per mL.

RESULTS

Between Dec 2016 and March 2017, among the 546 enrolled participants, data for 545 were analysed. The overall HIV prevalence was 40.2% [95% Confidence Interval (CI) 36.1-44.3]. Age-stratified prevalence increased from 22.1% (95% CI, 15.9-30.0) in the 14-19 year age group to 63.9% (95% CI, 55.1-71.9) among women ≥ 30 years (Χ2 trend P < 0.0001). Of the HIV positive participants, 84.5% (95% CI, 79.0-88.8) knew their HIV positive status, 98.3% (95% CI 95.1-99.4) who knew their status were on ART, and of those on ART, 95.9% (95% CI 91.8-98.0) were virally suppressed. Among all HIV-positives 90.8% (95% CI, 86.3-94.0) had achieved viral suppression, whilst those in the 14-19 year age group were least likely to be virally suppressed at 82.8% (95% CI 65.5-92.4) compared to those in the older age groups. Married women compared to those unmarried were more likely to have achieved viral suppression (PRR) of 1.11 (95% CI 1.05-1.18), P < 0.001.

CONCLUSIONS

The proportion of HIV positive pregnant women achieving viral suppression was encouraging though far short of the target towards achieving epidemic control. Importantly, adolescent pregnant women were less likely to know their HIV status and to achieve viral suppression, underscoring the public health implications of sustained risk of HIV transmission. Thus, greater effort and strong social support are essential to improve HIV knowledge of status and care continuum towards the goal to achieving HIV epidemic control. To "fast-track" the response to achieve HIV epidemic control and end the AIDS epidemic, the Joint United Nations Programme on HIV/AIDS (UNAIDS) set ambitious HIV testing and treatment targets for people living with HIV. Meeting these targets through scaling up testing for HIV, initiating and sustaining antiretroviral therapy (ART) to maintain viral suppression provides both therapeutic and preventive benefits with the potential to reduce HIV transmission. Viral suppression among pregnant adolescents and women living with HIV is crucial for the prevention of mother-to-child transmission of HIV including onward transmission to sexual partners. As a public health approach, in South Africa all pregnant women are offered routine HIV testing and immediate initiation of lifelong ART irrespective of CD4 cell count. It is, therefore, important to ascertain progress towards reaching the targets. The proportion of HIV positive pregnant adolescents and women achieving viral suppression was encouraging though far short of the target towards achieving epidemic control. Importantly, pregnant adolescents were less likely to know their HIV status and to achieve viral suppression, underscoring the public health implications of sustained risk of HIV transmission. Thus, greater effort and strong social support are essential to improve HIV knowledge of status and care continuum towards the goal to achieving HIV epidemic control.

Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan

Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular.

Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis.

Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention.

Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.

When Pregnancy Coincides with Positive Diagnosis of HIV: Accounts of the Process of Acceptance of Self and Motherhood among Women in South Africa

Literature has highlighted the unique period of vulnerability following an HIV diagnosis during pregnancy. Despite the high burden of HIV among pregnant women in South Africa, the experiences of women diagnosed with HIV during pregnancy have rarely been explored in isolation from those diagnosed at different times. This paper explored the experiences of women who were diagnosed with HIV when pregnant and assessed their emotional recovery beyond diagnosis. The study used a qualitative descriptive phenomenological approach to conduct interviews with women recruited from ART clinics in a health district in South Africa. Participants included 19 women sampled purposively. The interviews were transcribed verbatim and analysed following the thematic approach. Testing positive during pregnancy and being free of symptoms increased the shock, disbelief, and strong emotions exhibited. For the women, the diagnosis of HIV coincided with pregnancy and transformed pregnancy from excitement to anxiety. Although the transition from being HIV negative to becoming HIV positive and pregnant was overwhelming, with the passage of time, the women transitioned to feelings of acceptance. However, the process of acceptance was slow and varied, with some experiencing non-acceptance for extended periods. Non-acceptance of HIV diagnosis has serious adverse public health consequences for the individual. Integrating continuous HIV counselling and culturally appropriate psychosocial care into practice could foster acceptance for pregnant women with HIV diagnosis.