Articles tagged as "People living with HIV"

Living with HIV

Bazant ES, Boulay M. Factors associated with religious congregation members' support to people living with HIV/AIDS in Kumasi, Ghana. AIDS Behav 2007 Jan 6[Epub ahead of print].

Physical, social and economic constraints often limit the ability of people living with HIV to meet their basic needs. Community members are a valuable source of support for people living with HIV, although little is known about the types of support they provide or how to mobilise this support. Bazant and Boulay examined this issue by conducting a survey of 1200 members of 6 religious congregations in Kumasi, Ghana. A fifth of congregation members reported providing some support to people with HIV in the last 6 months, mostly through prayer, financial support, and counselling. Factors associated with providing support include having heard a congregation or tribal chief speaking about HIV, collective efficacy related to HIV, and perceived risk of becoming infected with HIV. The authors conclude that to enhance support to people with HIV, programmes should involve community leaders and encourage dialogue on ways to address the epidemic.

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Living with HIV

Williams AL. Perspectives on spirituality at the end of life: a meta-summary. Palliat Support Care 2006;4:407-17.

Williams undertook a meta-summary of the qualitative literature on spiritual perspectives of adults who are at the end of life to summarily analyze the research to date and identify areas for future research on the relationship of spirituality with physical, functional, and psychosocial outcomes in the health care setting. Included were all English language reports from 1966 to the present catalogued in PubMed, Medline, PsycInfo, and CINAHL, identifiable as qualitative investigations of the spiritual perspectives of adults at the end of life. The final sample included 11 articles, collectively representing data from 217 adults. The preponderance of participants had a diagnosis of cancer, those with AIDS, cardiovascular disease, and ALS were also represented. Approximately half the studies were conducted in the United States; others were performed in Australia, Finland, Scotland, and Taiwan. Following a process of theme extraction and abstraction, thematic patterns emerged and effect sizes were calculated. A spectrum of spirituality at the end of life encompassing spiritual despair (alienation, loss of self, dissonance), spiritual work (forgiveness, self-exploration, search for balance), and spiritual well-being (connection, self-actualization, consonance) emerged. The authors conclude that the findings from this meta-summary confirm the fundamental importance of spirituality at the end of life and highlight the shifts in spiritual health that are possible when a terminally ill person is able to do the necessary spiritual work. Existing end-of-life frameworks neglect spiritual work and consequently may be deficient in guiding research. The area of spiritual work is fertile ground for further investigation, especially interventions aimed at improving spiritual health and general quality of life among the dying.

Editors’ note: These results from an international study stimulate a desire for much more information on approaches that are effective in improving wellbeing and quality of life among those who are dying.


Ndinda C, Chimbwete C, McGrath N, Pool R, Mdp Group. Community attitudes towards individuals living with HIV in rural KwaZulu-Natal, South Africa. AIDS Care 2007;19:92-101.

Antenatal sero-prevalence rates of 30% and more have been reported in KwaZulu-Natal since 1998 and over 50% of all adult deaths in 2000 were due to AIDS. Understanding the changing social and cultural attitudes to AIDS is important in providing contextual information to aid the design of interventions. Ndinda and colleagues examined community attitudes towards individuals living with HIV. Eleven focus groups were conducted with men and women. Participants were asked to discuss how people living with HIV were treated within the family and community. The discussions were recorded and transcribed in isiZulu and then translated into English. These were coded using Nudist-6 software to identify key themes and sub-themes using content analysis. Gender and area differences were investigated. Generally participants expressed positive attitudes to the treatment of AIDS patients and felt that people living with HIV were being cared for within families. However, they reported more negative attitudes to those living with HIV by the general community and suggested these attitudes and acts of discrimination influenced disclosure. Discrimination included physical isolation and symbolism such as referring to them using a 'three finger' gesture. Participants also reported mixed responses to known HIV-positive individuals, ranging from sympathy to a lack of care, on the grounds that the person is certain to die. There are gender differences in terms of the attitudes towards people living with HIV. Compassion and hopelessness seem to be more common among women than men.

Editors’ note: It is important for communities to build on findings like these to constructively address negative attitudes and foster nurturing, positive attitudes.

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Living with HIV

Zachariah R, Fitzgerald M, Massaquoi M, Pasulani O, Arnould L, Makombe S, Harries AD. Risk factors for high early mortality in patients on antiretroviral treatment in a rural district of Malawi. AIDS 2006;20:2355-60.

Zacchariah and colleagues determined the cumulative proportion of deaths that occur within 3 and 6 months of starting ART, and identified risk factors that may be associated with such mortality, among adults started on ART in a rural district hospital in Thyolo, Malawi. Over a 2-year period (April 2003 to April 2005), the authors examined the mortality within the first 3 and 6 months of starting ART. A total of 1507 individuals (517 men and 990 women), whose median age was 35 years were included in the study. There were a total of 190 (12.6%) deaths on ART of which 116 (61%) occurred within the first 3 months (very early mortality) and 150 (79%) during the first 6 months of initiating ART. Significant risk factors associated with such mortality included WHO stage IV disease, a baseline CD4 cell count under 50 cells/mul and increasing grades of malnutrition. A linear trend in mortality was observed with increasing grades of malnutrition (P=0.001) and decreasing CD4 cell counts (P=0.001). Individuals who were severely malnourished (that is, body mass index less than 16.0 kg/m2) had a six times higher risk of dying in the first 3 months than those with a normal nutritional status. The authors conclude that among individuals starting ART, the body mass index and clinical staging could be important screening tools for use to identify and target individuals who, despite ART, are still at a high risk of early death.

Editors’ note: That severe malnourishment increased the risk of early mortality six-fold in patients starting antiretroviral treatment underlines strongly the importance of nutritional supplementation as a critical component of treatment programmes. In a number of countries, the World Food Programme is helping vulnerable individuals and their families to smooth the transition onto drug treatment, enable adherence to antiretroviral treatment regimens and improve survival.


Clifford GM, Goncalves MA, Franceschi S; for the HPV and HIV Study Group. Human papillomavirus types among women infected with HIV: a meta-analysis. AIDS 2006;20(18):2337-44.

HIV-positive women have a high prevalence of human papillomavirus (HPV) infection and are infected with a broader range of HPV types than HIV-negative women. However, it is not known to what extent these different types are associated with high-grade squamous intraepithelial lesions (HSIL) and cancer. Clifford and colleagues conducted a meta-analysis of HPV type-specific prevalence among HIV-positive women, stratified by geographical region and by cervical cytology: normal, atypical squamous cells of undetermined significance/low-grade squamous intraepithelial lesions (ASCUS/LSIL) or HSIL. In 20 studies, 5578 HIV-positive women were identified, largely from North America but also Africa, Asia, Europe and South/Central America. For 3230 women with no cytological abnormalities, prevalence was 36.3% for any HPV and 11.9% for multiple HPV types. The six most common high-risk HPV types were 16 (4.5%), 58 (3.6%), 18 (3.1%), 52 (2.8%), 31 (2.0%) and 33 (2.0%). HPV16 was also the most common type in 2053 HIV-positive women with ASCUS/LSIL and 295 with HSIL. Those with HSIL were significantly less likely to be infected with HPV16 (OR 0.6, 95%CI 0.4-0.7) than the general female population with HSIL. In contrast, HIV-positive women with HSIL were significantly more likely to be infected with HPV types 11, 18, 33, 51, 52, 53, 58 and 61, and with multiple HPV types. The authors conclude that the proportion of HIV-positive women with HPV16 rose with increasing severity of cervical lesions. Nevertheless, HPV16 remained underrepresented in HIV-positive women with HSIL, who showed a higher proportion of other HPV types and multiple types compared with the general female population with HSIL.

Editors’ note: HPV infection is the most common sexually transmitted infection in the world. This study found that HPV16 was the most common detectable HPV type in women with HIV infection, as it is in women without HIV infection, when the cervix was healthy or when cervical changes were at most low grade. The fact that women with high grade lesions had more of other HPV types and more multiple types may be due to the effects of immune deficiency. Correlating CD4 count with the predominance of certain HPV types and with cervical pathology will assist in predicting the potential impact of the new HPV vaccines for women with HIV infection or who subsequently acquire HIV infection.

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Living with HIV

Wolitski RJ, Flores SA, O'leary A, Bimbi DS, Gomez CA. Beliefs about personal and partner responsibility among HIV-seropositive men who have sex with men: measurement and association with transmission risk behaviour. AIDS Behav 2006 Nov 14 [Epub ahead of print].

Beliefs of people living with HIV about their own responsibility for preventing HIV transmission (personal responsibility) and their sex partners' responsibility for protecting themselves (partner responsibility) are poorly understood. A sample of 1163 HIV-seropositive men who have sex with men (55% men of colour) completed an A-CASI assessment of sexual behaviour and psychosocial measures. A two-dimensional model that represents four orientations toward responsibility was tested: (1) self-high personal and low partner responsibility, (2) other-low personal and high partner responsibility, (3) shared-high personal and high partner responsibility, and (4) diminished-low personal and low partner responsibility. The self-responsibility group demonstrated the lowest risk of HIV transmission and the other responsibility group had the highest risk. Intermediate risk was observed in the shared and diminished responsibility groups.

Editors’ note: Building on beliefs about responsibility (and also self-efficacy) to develop effective programming is a significant challenge but these are key elements in decision making and in behaviour within dyads, sexual or not, and literature outside the HIV field may throw some light on this.

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Living with HIV

Cotton S, Tsevat J, Szaflarski M, Kudel I, Sherman SN, Feinberg J, Leonard AC, Holmes WC. Changes in religiousness and spirituality attributed to HIV: are there sex and race differences? J Gen Intern Med 2006;21 Suppl 5:S14-20.

Having a serious illness such as HIV raises existential issues, which are potentially manifested as changes in religiousness and spirituality. Cotton and colleagues described changes in religiousness and spirituality of people with HIV, and determines if these changes differed by sex and race. Three-hundred and forty-seven adults with HIV from 4 sites were asked demographic, clinical, and religious/spiritual questions. Six religious/spiritual questions assessed personal and social domains of religiousness and spirituality. Eighty-eight participants (25%) reported being "more religious" and 142 (41%) reported being "more spiritual" since being diagnosed with HIV. Approximately 1 in 4 participants also reported that they felt more alienated by a religious group since their HIV diagnosis and approximately 1 in 10 reported changing their place of religious worship because of HIV. A total of 174 participants (50%) believed that their religiousness/spirituality helped them live longer. Fewer Caucasians than African Americans reported becoming more spiritual since their HIV diagnosis (37% versus 52%, P<0.015), more Caucasians than African Americans felt alienated from religious communities (44% versus 21%, P<.001), and fewer Caucasians than African Americans believed that their religiousness/spirituality helped them live longer (41% vs 68%, P<.001). There were no significantly different reported changes in religious and spiritual experiences by sex. In conclusion, many participants report having become more spiritual or religious since contracting HIV, though many have felt alienated by a religious group-some to the point of changing their place of worship. The authors conclude that clinicians conducting spiritual assessments should be aware that changes in religious and spiritual experiences attributed to HIV might differ between Caucasian and African Americans.

Editors’ note: These findings from the United States may also find resonance in other cultures.

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Living with HIV

Kumar A, Waterman I, Kumari G, Carter AO. Prevalence and correlates of HIV serostatus disclosure: a prospective study among HIV-infected postparturient women in Barbados. AIDS Patient Care STDS 2006;20:724-30.

Kumar and colleagues determined the prevalence of self-disclosure of HIV status among the postparturient HIV-infected women and described the correlates of disclosure among all known HIV-infected postparturient women in Barbados who delivered during 1997 through 2004. Sociodemographic data are routinely collected from all HIV-infected postparturient women. Data on disclosure were collected through one-to-one interview of the consenting women included in this study. One hundred thirty nine women were studied. Forty women (28.8%) had self-disclosed their HIV status to other people including their current sex partner. Among women who did not disclose their HIV status to anybody, 30 (30%) gave fear of stigmatization as the reason for nondisclosure, while 23 (23%) did not disclose their status as they feared abnormal reaction from their current sex partner and possible violence directed at them. Women who had disclosed their HIV status were more likely to use condoms during all sexual encounters, less likely to have had a subsequent pregnancy from a different sex partner, more likely to have a partner who had been tested for HIV, and more likely to be attending the centralized HIV clinic for follow-up and care compared to those who did not disclose. A substantial proportion of HIV-infected postparturient women never disclosed their result to a partner or a close relative. Lack of disclosure may have limited their ability to engage in preventive behaviours or to obtain the necessary emotional support for coping with their serostatus or illness.


Kang E, Rapkin BD, Dealmeida C. Are Psychological consequences of stigma enduring or transitory? A longitudinal study of HIV stigma and distress among Asians and Pacific Islanders living with HIV illness. AIDS Patient Care STDS 2006;20:712-23.

Cross-sectional findings have shed considerable light on the relationships between illness stigma and psychological outcomes among persons living with HIV in the United States. However, no studies have examined the possible long-term consequences of illness stigma on mental health among Asians and Pacific Islanders living with HIV, a group particularly vulnerable to HIV stigma due to ingrained sociocultural norms. This 2-year longitudinal study examined the relationship between five HIV-stigma factors (social rejection, negative self-worth, perceived interpersonal insecurity, financial insecurity, discretionary disclosure) and changes in psychological distress dimensions (self-esteem, hopelessness, dread, confused thinking, sadness, anxiety) among a convenience sample of 44 HIV-seropositive Asians and Pacific Islanders in New York City from 2002 to 2004. Undocumented Asians independently endorsed higher levels of perceived interpersonal insecurity and lower levels of self-esteem than documented participants at both baseline and 2-year follow-up. Results from hierarchical multiple regression analyses indicated that baseline social rejection and perceived interpersonal insecurity were significantly associated with changes in self-esteem at 2-year follow-up, controlling for baseline self-esteem and physical symptoms at follow-up. An interaction effect between baseline financial insecurity and discretionary disclosure was significantly associated with dread at 2-year follow-up. The authors conclude that findings highlight the importance of stigma reduction interventions that: (1) recognize multiple layers of stigma based sexual orientation, gender, and immigration status; and (2) address both individual and structural constraints that perpetuate HIV-stigma among Asians and Pacific Islanders in the United States.

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Living with HIV

Niccolai LM, D'Entremont D, et al. Unprotected intercourse among people living with HIV/AIDS: the importance of partnership characteristics. AIDS Care 2006;18:801-7.

Niccolai and colleagues determined the relative importance and interactive effects of partnership characteristics in unprotected intercourse among people living with HIV. They conducted an interview study among a convenience sample of people living with HIV in care. Of all the demographic, health status, risk history and behaviours and partnership covariates explored, only the partnership covariates were significantly associated with unprotected intercourse. Significant covariates included having a steady partner (OR 4.2, 95% CI 1.3-13.5), an HIV-positive partner (OR 2.7, 95%CI 1.0-6.9 versus HIV-negative partner), or an unknown serostatus partner (OR 4.6, 95%CI 1.1-18.3 versus HIV-negative partner), and men who have sex with men partnerships (OR 3.0, 95%CI 1.2-7.3). Partnership covariates explained 23% of the variance in unprotected intercourse, but other groups of covariates did not significantly improve model fit. Significant interaction terms between reported partner HIV status, partnership type and sexual orientation revealed the greatest likelihood of unprotected intercourse in two groups of individuals: those in steady relationships with HIV-positive partners and men who have sex with men in relationships with partners of unknown serostatus. Prevention programming for people living with HIV should focus on partnership characteristics.

Editors’ note: There are a variety of terms used to refer to such prevention programming, but a stronger message is conveyed about how best to design and implement effective programmes if we use the expression ‘for and by’ people living with HIV – it’s part of GIPA!


Atashili J, Kalilani L, Adimora AA. Efficacy and clinical effectiveness of influenza vaccines in HIV-infected individuals: a meta-analysis. BMC Infect Dis 2006;6:138. http://www.biomedcentral.com/1471-2334/6/138

Though influenza vaccines are the cornerstone of medical interventions aimed at protecting individuals against epidemic influenza, their effectiveness in HIV infected individuals is not certain. With the recent detection of influenza strains in countries with high HIV prevalence rates, Atashili and colleagues evaluated the current evidence on the efficacy and clinical effectiveness of influenza vaccines in HIV-infected individuals. The authors used electronic databases to identify studies assessing efficacy or effectiveness of influenza vaccines in HIV patients. They included studies that compared the incidence of culture- or serologically-confirmed influenza or clinical influenza-like illness in vaccinated to unvaccinated HIV infected individuals. Characteristics of study participants were independently abstracted and the risk difference (RD), the number needed to vaccinate to prevent one case of influenza (NNV), and the vaccine effectiveness (VE) computed. They identified six studies that assessed the incidence of influenza in vaccinated HIV-infected subjects. Four of these studies compared the incidence in vaccinated versus unvaccinated subjects. These involved a total of 646 HIV-infected subjects. In all the 4 studies, the incidence of influenza was lower in the vaccinated compared to unvaccinated subjects with RD ranging from -0.48 (95% CI -0.63 to -0.34) to -0.15 (95% CI -0.25 to 0.05); implying that 3 to 7 people would need to be vaccinated to prevent one case of influenza. Vaccine effectiveness ranged from 27% to 78%. A random effects model was used to obtain a summary RD of -0.27 (95%CI -0.42 to -0.11). There was no evidence of publication bias. The authors conclude that current evidence, though limited, suggests that influenza vaccines are moderately effective in reducing the incidence of influenza in HIV-infected individuals. With the threat of a global influenza pandemic, there is an urgent need to evaluate the effectiveness of influenza vaccines in trials with a larger number of representative HIV-infected persons.

 Editors’ note: Ensuring that the sample size of people living with HIV within influenza vaccine trials will permit conclusions to be drawn about vaccine effects will be a challenge if these are carried out primarily in low HIV prevalence countries.

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Greater Involvement of People Living with HIV

Chung K, Lounsbury DW. The role of power, process, and relationships in participatory research for statewide HIV/AIDS programming. Soc Sci Med 2006 Jul 5; [Epub ahead of print] http://www.sciencedirect.com/

Participatory, community-based research is relatively new to mainstream medical research, but it is not new to health research. Participation in research is often conceptualised as a continuum in which different levels of participation imply different amounts of community control over the process and outcomes. At one end lies the conventional research situation in which community members are passive participants in the research process and have little influence over the process or outcome. At the other end lies a far more empowering situation in which community members work as equal partners to define and execute the research as well as to determine its applications. Theoretically, participatory research is situated at this far end of the continuum. Chung and Lounsbury present a case study of a participatory process that was used to understand the needs of persons living with HIV in a US state. The case illustrates that participation in a community-based research project is a dynamic phenomenon that must be negotiated among an evolving web of roles and relationships. Using a continuum to model the multiple modes of community participation, the authors follow the changing nature of participation over the course of a single project. Their analysis illustrates the different levels of participation given by the continuum as well as the dynamic nature of participation. A shared understanding of participation evolves as the roles and relationships of those involved are negotiated and renegotiated. However, lack of reflection over power differentials can lead to disempowering outcomes even after achieving a seemingly participatory process. In conclusion, Chung and Lounsbury say, this case reveals that failing to resolve divergent assumptions about power and purpose can lead to fissures that are difficult to overcome.

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Care and Support

Li L, Wu S, et al. Understanding family support for people living with HIV/AIDS in Yunnan, China. AIDS Behav 2006 May 31 [Epub ahead of print]

This study examines how family support affects people living with HIV in China. The authors conducted in-depth, semi-structured interviews (n=30) with people living with HIV who were infected through different routes (e.g., injection drug use, sex) and of different age groups. They found that all of the participants were in great need of help and the primary source of support came from their families. Family support included financial assistance, support in the disclosure process, daily routine activities, medical assistance, or psychological support. This study illustrates that the support provided by family makes multiple levels of positive impact on people living with HIV, suggesting the importance of including families in HIV programming.

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