Articles tagged as "Gender"

Feelings of regret after HIV status disclosure: prevalence, trends, and determinants

Was it a mistake to tell others that you are infected with HIV?: factors associated with regret following HIV disclosure among people living with HIV in five countries (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). Results from a community-based research.

Henry E, Bernier A, Lazar F, Matamba G, Loukid M, Bonifaz C, Diop S, Otis J, Préau M; The Partages study group. AIDS Behav. 2014 Dec 23. [Epub ahead of print]

This study examined regret following HIV serostatus disclosure and associated factors in under-investigated contexts (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). A community-based cross-sectional study was implemented by a mixed consortium [researchers/community-based organizations (CBO)]. Trained CBO members interviewed 1500 PLHIV in contact with CBOs using a 125-item questionnaire. A weighted multivariate logistic regression was performed. Among the 1212 participants included in the analysis, 290 (23.9 %) declared that disclosure was a mistake. Female gender, percentage of PLHIV's network knowing about one's seropositivity from a third party, having suffered rejection after disclosure, having suffered HIV-based discrimination at work, perceived seriousness of infection score, daily loneliness, property index and self-esteem score were independently associated with regret. Discrimination, as well as individual characteristics and skills may affect the disclosure experience. Interventions aiming at improving PLHIV skills and reducing their social isolation may facilitate the disclosure process and avoid negative consequences.

Abstract access 

Editor’s notes: Anticipated and perceived consequences of disclosing one’s HIV status are recognized as important drivers for HIV disclosure. This community-based study looked at the experience of disclosing one’s HIV status, and the emotions that were associated with disclosure. The study was nested within a larger cross-sectional research project. 1500 people living with HIV (PLHIV) from Ecuador, the Democratic Republic of the Congo (DRC), Mali, Romania, and Morocco were included in the study. Respondents were asked ‘Was it a mistake to tell others that you are infected with HIV?’ and to answer either ‘yes’ or ‘no.' Participants also responded to questions about the process of disclosure. Among people that had disclosed their status, some 23.9% said that it was a mistake to do so. Almost 40% of participants said that a person in their network learned about their status from a third party. More than 17% of participants responded that they faced rejection and eight percent of participants suffered discrimination at work following disclosure. But this varied greatly across countries. Factors associated with feeling regret after disclosing one’s status included being a female, perceived seriousness of HIV infection, and feeling lonely every day. This study highlights the fact that status disclosure can be emotional and stressful for people living with HIV. This suggests that people living with HIV must weigh the costs and benefits of disclosure before doing so and programmes that empower them to make informed decisions about disclosure may be beneficial. 

Africa, Europe, Latin America
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HIV and disability – a stronger link than perhaps we thought?

When I was no longer able to see and walk, that is when I was affected most: experiences of disability in people living with HIV in South Africa.

Hanass-Hancock J, Myezwa H, Nixon SA, Gibbs A. Disabil Rehabil. 2014 Dec 19:1-11. [Epub ahead of print]

Abstract Purpose: HIV-related disability is an emerging issue in countries where HIV is endemic. This study aimed to understand experiences of disability in patients living with HIV in South Africa using the International Classification of Functioning, Disability and Health (ICF) as a guiding framework.

Methods: In-depth interviews were conducted with 19 HIV-positive people receiving ART through a public hospital in KwaZulu-Natal. Data were analyzed using collaborative qualitative content analysis.

Results: Participants described a variety of impairments related to mental, sensory, neuromusculoskeletal, skin, cardiovascular, digestive or reproductive systems. A tenuous relationship was evident between HIV and mental health impairments and the experience of other disabilities. Impairments affected participants' activity levels, especially mobility, domestic life, self-care and ability to work. Activity limitations affecting livelihood were often of more concern to participants than the impairments. Furthermore, women and men appeared to experience disability related to activities relevant to gendered norms in their cultural context.

Conclusions: More understanding of the intersections among HIV, disability, gender and livelihood is needed. To respond to the increased need to manage disability within HIV care in Africa, HIV programs should include rehabilitative approaches, address concerns related to livelihoods in households with disability and consider gender differences in the experience of disability.

Implications for Rehabilitation: HIV, its opportunistic infections and the treatments associated to them are related to health conditions and impairments that have the potential to develop into disability. Rehabilitation professionals in HIV endemic countries have therefore a larger and changing number of people living with HIV and need to consider the impact of the disease on the rehabilitation process. Mental health issues and disability might be interrelated and affect antiretroviral treatment (ART) adherence. Hence, rehabilitation has to use a holistic approach and integrate different therapy approaches (e.g. physiotherapy and mental health). The experience of living with HIV and developing disability has unreflected gender dynamics that need to be considered in rehabilitative care. Hence, the rehabilitation process has to consider the cultural realities and gendered experience of the condition. The study highlights the interrelationship between disability levels, the influence of environmental and social factors, and the changing experience related to gender. Hence, rehabilitation professionals in resource-poor settings have to go beyond the clinical response and therapy approaches in order to improve the activity and participation of people with disabilities and those living with HIV in their homes and communities. Community or home-based care might be avenues to further explore.

Abstract access 

Editor’s notes: While the existence of disability among people living with HIV and on antiretroviral therapy (ART) has been reported, few studies have investigated the individual’s experience of disability. This important study from South Africa aims to fill that gap. The authors used WHO International Classification of Functioning, Disability and Health (ICF) to guide their interviews and the analysis. They systematically sampled participants from an antiretroviral treatment clinic at a public hospital in KwaZulu-Natal. Importantly they did not purposely choose people with a visible disability because they wished to capture the perspectives of people who appeared to being doing well on ART as well as people who may have a visible impairment. No screening for disability was done prior to recruitment in the study. Ten of the 19 participants had no visible disability, but 17 out of 19 reported challenges at the impairment level of disability. These challenges were often related to mental function, sensory function and pain, headaches, painful feet and vision problems (which in some cases seemed to be linked to TB treatment). These different impairments affected mobility, social interactions, ability to make a living and self-esteem. Not all of these impairments were visible nor necessarily reported to clinic staff who perceived many of these people to be ‘doing well’ on ART.  The authors illustrate in this small but important study a great diversity of experience of disability across a small number of people in one clinic in South Africa. They highlight the importance of understanding the social and environmental factors which influence individual experience. Most importantly they stress the need to pay attention to impairment and the rehabilitation support that may be needed, even for people who appear to be doing well on medication.

Africa
South Africa
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School and family factors interact to influence sexual behaviour in adolescent girls

Multiple sexual partnerships among female adolescents in rural Uganda: the effects of family structure and school attendance.

Pilgrim NA, Ahmed S, Gray RH, Sekasanvu J, Lutalo T, Nalugoda F, Serwadda D, Wawer MJ. Int J Adolesc Med Health. 2014 Nov 21. pii: /j/ijamh.ahead-of-print/ijamh-2014-0032/ijamh-2014-0032.xml. doi: 10.1515/ijamh-2014-0032. [Epub ahead of print]

Background: A better understanding is needed of the contextual factors that influence HIV risk behaviors among female adolescents in sub-Saharan Africa. The objectives of this study were to assess the influence of family structure on lifetime sexual partners and on the number of sexual partners in the last year among female adolescents in rural Rakai, Uganda. In addition, the study assessed whether the influence of family structure on these outcomes differed by the school attendance status of the adolescents.

Methods: The sample consisted of 2337 unmarried adolescent girls, aged 15-19, enrolled in the Rakai Community Cohort Study. The last survey interview within the time period of 2001-2008 available for each girl was used. Analyses were stratified by age (15-17 year olds and 18-19 year olds) and school status. Multinomial logistic and poisson regressions were used.

Results: Living in a household with a biological father was protective against both outcomes. Family structure was not associated with the outcomes among in-school adolescents but it was significantly associated with the outcomes among out-of-school adolescents.

Conclusions: The findings suggest that understanding the familial context in which female adolescents develop, as well as its interaction with school attendance, is important for HIV prevention efforts. Both research and programmatic initiatives must consider the interplay between the family and school domains when considering ways to reduce HIV acquisition among adolescent women.

Abstract access

Editor’s notes: This study addresses the key issue of adolescent sexual behaviour among unmarried girls which itself has significant implications for HIV and other STI risk. Only about 40% of girls in this study lived in a family structure which included a biological father in the household. Living with their own father was protective against having multiple partners. The authors highlight that cultural factors may lead to reverse causality behind this finding – including the fact that girls who got pregnant were made to leave the parental home. However, the biological father’s role in protecting daughters from sexual advances and exploitation is also suggested as an underlying reason. A novel finding of this study was the fact that family structure influenced sexual behaviour of non-school going girls but did not influence school-going girls. It is unclear whether school-attendance was itself protective or whether girls who went to school came from more supportive backgrounds in the first place. The authors emphasise that more research is needed to understand the pathways underlying this finding.

Africa
Uganda
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Why pregnant women and mothers living with HIV do not access, or do not stay in care

A systematic review of individual and contextual factors affecting ART initiation, adherence, and retention for HIV-infected pregnant and postpartum women.

Hodgson I, Plummer ML, Konopka SN, Colvin CJ, Jonas E, Albertini J, Amzel A, Fogg KP. PLoS One. 2014 Nov 5;9(11):e111421. doi: 10.1371/journal.pone.0111421. eCollection 2014.

Background: Despite progress reducing maternal mortality, HIV-related maternal deaths remain high, accounting, for example, for up to 24 percent of all pregnancy-related deaths in sub-Saharan Africa. Antiretroviral therapy (ART) is effective in improving outcomes among HIV-infected pregnant and postpartum women, yet rates of initiation, adherence, and retention remain low. This systematic literature review synthesized evidence about individual and contextual factors affecting ART use among HIV-infected pregnant and postpartum women.

Methods: Searches were conducted for studies addressing the population (HIV-infected pregnant and postpartum women), intervention (ART), and outcomes of interest (initiation, adherence, and retention). Quantitative and qualitative studies published in English since January 2008 were included. Individual and contextual enablers and barriers to ART use were extracted and organized thematically within a framework of individual, interpersonal, community, and structural categories.

Results: Thirty-four studies were included in the review. Individual-level factors included both those within and outside a woman's awareness and control (e.g., commitment to child's health or age). Individual-level barriers included poor understanding of HIV, ART, and prevention of mother-to-child transmission, and difficulty managing practical demands of ART. At an interpersonal level, disclosure to a spouse and spousal involvement in treatment were associated with improved initiation, adherence, and retention. Fear of negative consequences was a barrier to disclosure. At a community level, stigma was a major barrier. Key structural barriers and enablers were related to health system use and engagement, including access to services and health worker attitudes.

Conclusions: To be successful, programs seeking to expand access to and continued use of ART by integrating maternal health and HIV services must identify and address the relevant barriers and enablers in their own context that are described in this review. Further research on this population, including those who drop out of or never access health services, is needed to inform effective implementation.

Abstract Full-text [free] access

Editor’s notes: This systematic review is one of three by the same team, related to HIV and maternal mortality. The review findings illustrate that the individual and contextual factors which affect antiretroviral therapy (ART) initiation, adherence and retention for pregnant/postpartum women living with HIV are numerous. Fears over disclosure, and consequent stigma and discrimination feature in many of the studies reviewed. Practical barriers might be overcome, by making services more accessible. The lack of knowledge about HIV and treatment among some women may be addressed through information campaigns. However, the fear of negative consequences as a result of disclosure, even to health workers, presents significant barriers to care. This is something that is of particular note as Option B+ is rolled out. An important strength of this review is the combination of qualitative and quantitative studies. The meticulous description of the approach to the review is also welcome. The authors’ call for ‘consistent, standardised and appropriate measures of adherence and retention’ with a ‘longitudinal component’, is a valuable suggestion as the performance of countries in providing Option B+ begins to be compared.

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Home visits by community workers in South Africa improve maternal and child outcomes

A cluster randomised controlled effectiveness trial evaluating perinatal home visiting among South African mothers/infants.

Rotheram-Borus MJ, Tomlinson M, le Roux IM, Harwood JM, Comulada S, O'Connor MJ, Weiss RE, Worthman CM. PLoS One. 2014 Oct 23;9(10):e105934. doi: 10.1371/journal.pone.0105934. eCollection 2014.

Background: Interventions are needed to reduce poor perinatal health. We trained community health workers (CHWs) as home visitors to address maternal/infant risks.

Methods: In a cluster randomised controlled trial in Cape Town townships, neighbourhoods were randomised within matched pairs to 1) the control, healthcare at clinics (n = 12 neighbourhoods; n = 594 women), or 2) a home visiting intervention by CBW trained in cognitive-behavioural strategies to address health risks (by the Philani Maternal, Child Health and Nutrition Programme), in addition to clinic care (n = 12 neighbourhoods; n = 644 women). Participants were assessed during pregnancy (2% refusal) and 92% were reassessed at two weeks post-birth, 88% at six months and 84% at 18 months later. We analysed 32 measures of maternal/infant well-being over the 18 month follow-up period using longitudinal random effects regressions. A binomial test for correlated outcomes evaluated overall effectiveness over time. The 18 month post-birth assessment outcomes also were examined alone and as a function of the number of home visits received.

Results: Benefits were found on 7 of 32 measures of outcomes, resulting in significant overall benefits for the intervention compared to the control when using the binomial test (p = 0.008); nevertheless, no effects were observed when only the 18 month outcomes were analyzed. Benefits on individual outcomes were related to the number of home visits received. Among women living with HIV, intervention mothers were more likely to implement the PMTCT regimens, use condoms during all sexual episodes (OR = 1.25; p = 0.014), have infants with healthy weight-for-age measurements (OR = 1.42; p = 0.045), height-for-age measurements (OR = 1.13, p<0.001), breastfeed exclusively for six months (OR = 3.59; p<0.001), and breastfeed longer (OR = 3.08; p<0.001). Number of visits was positively associated with infant birth weight ≥2500 grams (OR = 1.07; p = 0.012), healthy head-circumference-for-age measurements at 6 months (OR = 1.09, p = 0.017), and improved cognitive development at 18 months (OR = 1.02, p = 0.048).

Conclusions: Home visits to neighbourhood mothers by CHWs may be a feasible strategy for enhancing maternal/child outcomes. However, visits likely must extend over several years for persistent benefits.

Abstract  Full-text [free] access

Editor’s notes: This trial combines two major trends in the delivery of health care. These include the shift of HIV services from specialist to generalist providers, and task-sharing between generalist and community providers. Community-based workers (CBW) from the Philani Maternal, Child Health and Nutrition Programme in Cape Town, South Africa were recruited to provide and apply health information about maternal and child health, HIV, alcohol use and nutrition to 644 perinatal women in the programme communities. The CBWs complemented the standard of care for health services, which were also available to 594 perinatal women in the control communities. About a quarter of participants were living with HIV. This study is notable for its real-world applicability through its trial design, provision of services to the entire population of eligible perinatal women, range of behavioural and clinical outcomes and rigorous analytic methods. At six months post-partum, women living with HIV in the programme arm were more likely to implement the prevention of mother-to-child regimen and to use condoms with their sex partners. Additionally, the children of these women had improved growth characteristics. Future research must determine whether CBWs can improve the other outcomes assessed in this trial, the cost-effectiveness of the CBWs, and how these gains can be extended to 18 months post-partum.

Africa
South Africa
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Does pregnancy accelerate HIV progression?

Pregnancy and HIV disease progression: a systematic review and meta-analysis.

Calvert C, Ronsmans C. Trop Med Int Health. 2014 Oct 31. doi: 10.1111/tmi.12412. [Epub ahead of print]

Objective: To assess whether pregnancy accelerates HIV disease progression.

Methods: Studies comparing progression to HIV-related illness, low CD4 count, AIDS-defining illness, HIV-related death, or any death in HIV-infected pregnant and non-pregnant women were included. Relative risks (RR) for each outcome were combined using random effects meta-analysis and were stratified by antiretroviral therapy (ART) availability.

Results: 15 studies met the inclusion criteria. Pregnancy was not associated with progression to HIV-related illness [summary RR: 1.32, 95% confidence interval (CI): 0.66-2.61], AIDS-defining illness (summary RR: 0.97, 95%CI: 0.74-1.25) or mortality (summary RR: 0.97, 95%CI: 0.62-1.53), but there was an association with low CD4 counts (summary RR: 1.41, 95%CI: 0.99-2.02) and HIV-related death (summary RR: 1.65, 95%CI: 1.06-2.57). In settings where ART was available, there was no evidence that pregnancy accelerated progress to HIV/AIDS-defining illnesses, death and drop in CD4 count. In settings without ART availability, effect estimates were consistent with pregnancy increasing the risk of progression to HIV/AIDS-defining illnesses and HIV-related or all-cause mortality, but there were too few studies to draw meaningful conclusions.

Conclusions: In the absence of ART, pregnancy is associated with small but appreciable increases in the risk of several negative HIV outcomes, but the evidence is too weak to draw firm conclusions. When ART is available, the effects of pregnancy on HIV disease progression are attenuated and there is little reason to discourage healthy HIV-infected women who desire to become pregnant from doing so.

Abstract access 

Editor’s notes: The suppression of cell-mediated immunity during pregnancy is associated with increased susceptibility to and/or severity of many infections. Therefore the question of whether pregnancy accelerates HIV disease progression in HIV-positive women is pertinent. A previous systematic review published in the late 1990s found weak evidence that the odds of acquiring an AIDS-defining illness or death were higher among HIV-positive pregnant women than HIV-positive non-pregnant women. The findings from this meta-analysis also suggest that in the absence of antiretroviral therapy (ART), pregnancy is associated with an increase in the risk of several negative HIV outcomes. Fortunately ART appears to diminish the effects of pregnancy on HIV progression.  The authors also draw attention to the methodological weaknesses of the studies included and highlight the need for better quality data, examining whether pregnancy aggravates HIV progression.

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`Real men’ do not need healthcare: men and treatment seeking in Malawi

Control, struggle, and emergent masculinities: a qualitative study of men's care-seeking determinants for chronic cough and tuberculosis symptoms in Blantyre, Malawi.

Chikovore J, Hart G, Kumwenda M, Chipungu GA, Desmond N, Corbett L.BMC Public Health. 2014 Oct 9;14:1053. doi: 10.1186/1471-2458-14-1053.

Background: Men's healthcare-seeking delay results in higher mortality while on HIV or tuberculosis (TB) treatment, and implies contribution to ongoing community-level TB transmission before initiating treatment. We investigated masculinity's role in healthcare-seeking delay for men with TB-suggestive symptoms, with a view to developing potential interventions for men.

Methods: Data were collected during March 2011 - March 2012 in three high-density suburbs in urban Blantyre. Ten focus group discussions were carried out of which eight (mixed sex = two; female only = three; male only = three) were with 74 ordinary community members, and two (both mixed sex) were with 20 health workers. Individual interviews were done with 20 TB patients (female =14) and 20 un-investigated chronic coughers (female = eight), and a three-day workshop was held with 27 health stakeholder representatives.

Results: An expectation to provide for and lead their families, and to control various aspects of their lives while facing limited employment opportunities and small incomes leaves men feeling inadequate, devoid of control, and anxious about being marginalised as men. Men were fearful about being looked at as less than men, and about their wives engaging in extramarital sex without ability to detect or monitor them. Control was a key defining feature of adequate manhood, and efforts to achieve it also led men into side-lining their health. Articulate and consistent concepts of men's bodily strength or appropriate illness responses were absent from the accounts.

Conclusions: Facilitating men to seek care early is an urgent public health imperative, given the contexts of high HIV/AIDS prevalence but increasingly available treatment, and the role of care-seeking delay in TB transmission. Men's struggles trying to achieve ideal images seem to influence their engagement with their health. Ambiguous views regarding some key masculinity representations and the embrace of less harmful masculinities raise questions about some common assumptions that guide work with men. Apparent 'emergent masculinities' might be a useful platform from which to support the transformation of harmful masculinity. Finally, the complex manifestations of masculinity indicate the need for interventions targeting men in health and TB control to assume supportive, multidimensional and long-term outlooks.

Abstract  Full-text [free] access

Editor’s notes: The differences between men and women’s willingness to seek healthcare have been described in many different settings. This paper sets out the detailed results from a cross-sectional qualitative study looking at men’s care seeking practices for tuberculosis/chronic cough in Malawi. As well as describing perceptions of how a man should behave in society, and what this means for managing health, the authors examine how masculinity influences ill-health responses. Some men delay treatment seeking, because it is not manly to give in to symptoms. Men should publicly show an ability to put up with poor health or employ alcohol or exercise to chase away sickness. While the focus of this paper is on treatment seeking for tuberculosis, the authors draw parallels with the emerging literature on masculinity and HIV-treatment access. Making treatment available will not be enough; efforts have to be made to develop programmes to support and sustain men on treatment.

Avoid TB deaths
Africa
Malawi
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Tensions between the role of motherhood and the role of sex worker

'If you have children, you have responsibilities': motherhood, sex work and HIV in southern Tanzania.

Beckham SW, Shembilu CR, Winch PJ, Beyrer C, Kerrigan DL. Cult Health Sex. 2014 Oct 1:1-15. [Epub ahead of print]

Many female sex workers begin sex work as mothers, or because they are mothers, and others seek childbearing. Motherhood may influence women's livelihoods as sex workers and their subsequent HIV risks. We used qualitative research methods (30 in-depth interviews and three focus group discussions) and employed Connell's theory of Gender and Power to explore the intersections between motherhood, sex work, and HIV-related risk. Participants were adult women who self-reported exchanging sex for money within the past month and worked in entertainment venues in southern Tanzania. Participants had two children on average, and two-thirds had children at home. Women situated their socially stigmatised work within their respectable identities as mothers caring for their children. Being mothers affected sex workers' negotiating power in complex manners, which led to both reported increases in HIV-related risk behaviours (accepting more clients, accepting more money for no condom, anal sex), and decreases in risk behaviours (using condoms, demanding condom use, testing for HIV). Sex workers/mothers were aware of risks at work, but with children to support, their choices were constrained. Future policies and programming should consider sex workers' financial and practical needs as mothers, including those related to their children such as school fees and childcare.

Abstract access 

 Editor’s notes: This important research sought to understand how sex workers negotiate this identity alongside their identity as mothers. Sex workers in sub-Saharan Africa have a greater risk of acquiring HIV than the general population. Many of these women are mothers. The authors conducted qualitative research with sex workers in southern Tanzania and using Cornell’s theory of Gender and Power as a theoretical frame, explored the intersections between motherhood, sex work and HIV related risk behaviours. This theory outlines four structures of gender: labour, power, emotional, and symbolic relations. Their analysis revealed three key themes. These included motherhood/respectability versus sex work/stigma; for the children; and motherhood/power, and HIV risk. The first theme highlights how for these women that motherhood denotes respect in contrast to the stigma evoked by sex work. Thus women often emphasised their role as mothers over that as sex workers. The second theme emphasised that for these women the ideal mother has the financial support of a husband and their role is to care for their children. However, as many of these women were unable to rely on partners, sex work enabled them to care for their children and ensure their well-being. The third theme, revealed a contradiction. Being a mother could either empower their role as a sex worker, drawing on this respectability and enabling them to negotiate higher payments from clients; or seeking higher payments for risky sexual acts such as anal sex or sex without a condom to ensure the well-being of their children. The authors conclude that in relation to Cornell’s theory these women are compromised in terms of labour both as mothers and as stigmatised sex workers and this is also related to lack of power in both of these areas. In emotional relations, women’s bond with their children is highly important and drove their need to earn money through sex work. Further, in terms of symbolic relations women used the role of motherhood to ensure their dignity and respect.

Africa
United Republic of Tanzania
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The challenge of living with HIV and being a ‘real man’ – the intersection of stigma and masculinity

Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes.

Mburu G, Ram M, Siu G, Bitira D, Skovdal M, Holland P. BMC Public Health. 2014 Oct 11;14:1061. doi: 10.1186/1471-2458-14-1061.

Background: Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men's health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men's participation in and utilisation of HIV services in Uganda.

Methods: Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked.

Results: Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men's participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men's risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a 'sick role'; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men's involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability.

Conclusion: To improve men's involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes.

Abstract  Full-text [free] access

Editor’s notes: Both stigma and masculinity can affect men’s health seeking behaviour. This article builds on previous research in Uganda on how stigma affects how men cope with HIV. It draws on the concept of intersectionality to examine how the structural vulnerabilities of stigma and masculinity intersect. It explores the perceived influence of this intersection, and the extent to which it may further disadvantage men in their participation and utilisation of HIV services. Drawing on qualitative research from eastern Uganda, this study explores how various signifiers of masculinity undermined men’s health by restricting their participation in peer support groups and HIV services. Signifiers of masculinity included physical and emotional strength, respectability, and involvement in multiple sexual relationships. Some signifiers of masculinity were also often intertwined with HIV stigma, for example men’s reluctance to adopt a sick role was reinforced by the fact that HIV was a stigmatised disease. Furthermore, shame, secrecy, a perceived sense of powerlessness, and loss of respect were often contrary to masculine notions of respect. Similarly, stigma was also shown to interact with masculine provider role identities. As a result, men sought to avoid the additional shame of not being able to provide for their families by planning to work, and therefore not prioritising clinic appointments or participation in unpaid group activities. 

Through this research, the authors argue that stigma and masculinity, rather than being understood as unilateral variables, should be considered in conjunction. This is important in order to explore how these variables might amplify or otherwise modify each other to determine men’s willingness to participate in HIV services. The authors highlight a number of implications of their research. First, HIV programmes should mobilise communities to discuss the possible harmful effects of adhering to prevalent masculine notions of risk-taking, independence, and emotional control. Second, social protection and livelihood activities targeting men living with HIV and their families should be integrated into HIV programmes and peer support group activities. Third, social support networks of men living with HIV should be bolstered in order to help men deal with stigma.

Africa
Uganda
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Staying on Option B+: why post-partum women are dropping out of HIV care in a Johannesburg clinic

What they wanted was to give birth; nothing else: barriers to retention in option B+ HIV care among postpartum women in South Africa.

Clouse K, Schwartz S, Van Rie A, Bassett J, Yende N, Pettifor A. J Acquir Immune Defic Syndr. 2014 Sep 1;67(1):e12-8. doi: 10.1097/QAI.0000000000000263.

Background: Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count.

Methodology: We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa.

Results: Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26-34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the baby's health than their own (29.2%, 14/48), women were "ignorant" or "irresponsible" (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma.

Conclusions: We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mother's own health must be embraced by health-care workers and public health programs.

Abstract access 

Editor’s notes: This paper addresses a key knowledge gap which is, why do post-partum women living with HIV drop out of HIV care, despite having the opportunity to access ongoing HIV care? This paper presents the findings of a qualitative study conducted with women in a Johannesburg clinic who are being offered option B+. Option B+, seeks to initiate all HIV-positive pregnant women on lifelong highly active antiretroviral therapy (ART) regardless of CD4 count. Its success depends on the proportion of women who are retained in care and continue to adhere to treatment.

While the study found that very few women admitted that they themselves would stop taking their ART, they cited multiple reasons for other women to stop doing so. Many of these reasons have been discussed before, such as prioritising the health of their baby and having been harshly treated by healthcare workers during their delivery. A key issue identified in the paper is that once women have given birth they describe no longer having a ‘legitimate’ reason, in this case antenatal care, to continue attending a clinic. So we learn that being pregnant provides a cover to legitimise clinic attendance and women are able to receive HIV care without the risk of arousing suspicion. This is revealing about the ongoing HIV stigma and the challenges that a woman faces in explaining any regular visits to a healthcare facility to partners, family members, employers and others within their community. This illustrates the complex negotiations involved for many women in leaving their work commitments, formal or informal, to regularly attend an HIV clinic.

This paper is valuable because it shows us that unfortunately, even if costs can be waived, access may still be impeded by the persistent constraints involved in the management of non-disclosure. We may also learn a valuable methodological lesson from this study. To access information and opinions about drop-out and disengagement in HIV care, research may be more effective if studies allow individuals to talk about such issues indirectly through other people’s experiences rather than their own. This will address issues of social desirability bias in clinic based research. 

Africa
South Africa
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