Articles tagged as "People living with HIV"

We need to listen to people living with HIV who refuse or delay starting ART: lessons from Australia

On the margins of pharmaceutical citizenship: not taking HIV medication in the "treatment revolution" era.

Persson A, Newman CE, Mao L, de Wit J. Med Anthropol Q. 2016 Jan 12. doi: 10.1111/maq.12274. [Epub ahead of print]

With the expanding pharmaceuticalization of public health, anthropologists have begun to examine how biomedicine's promissory discourses of normalization and demarginalization give rise to new practices of and criteria for citizenship. Much of this work focuses on the biomedicine-citizenship nexus in less-developed, resource-poor contexts. But how do we understand this relationship in resource-rich settings where medicines are readily available, often affordable, and a highly commonplace response to illness? In particular, what does it mean to not use pharmaceuticals for a treatable infectious disease in this context? We are interested in these questions in relation to the recent push for early and universal treatment for HIV infection in Australia for the twin purposes of individual and community health. Drawing on Ecks's concept of pharmaceutical citizenship, we examine the implications for citizenship among people with HIV who refuse or delay recommended medication. We find that moral and normative expectations emerging in the new HIV "treatment revolution" have the capacity to both demarginalize and marginalize people with HIV.

Abstract 

Editor’s notes: Following the release of WHO ‘Guidelines on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV’ at the end of September 2015, there has been growing momentum to roll out treatment to all people living with HIV. This important paper highlights an important issue affecting the provision of antiretroviral therapy (ART) to all people living with HIV, regardless of CD4 cell count. Not everyone wants to start treatment promptly. The authors interviewed 27 people in Australia who had declined to start ART. Ten of these people had never used ART, while the remaining 17 had started and then stopped therapy. There were many reasons why these people chose not to start or continue with ART. These reasons included fears over side-effects and the commitment to life-long therapy. Some doubted that they needed ‘treatment’ because they were well. A few were sceptical about the efficacy of the drugs.  These reasons for delaying treatment are being echoed in research from other parts of the world. The authors of this paper note that if treatment is promoted as ‘normal’, then people who decline ART risk marginalisation for ‘not doing the right thing’. This, they suggest, is particularly the case in places where ART are readily and freely available, like Australia. The authors conclude by highlighting the importance of listening to people who do not want to start ART, and understanding their reservations, while ensuring they do not become marginalised.

Oceania
Australia
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When are children ‘mature enough’ to know their HIV status? Caregivers’ and children’s perspectives on discussing HIV and ART at home in Jinja District, Uganda

Tensions in communication between children on antiretroviral therapy and their caregivers: a qualitative study in Jinja district, Uganda.

Kajubi P, Whyte SR, Kyaddondo D, Katahoire AR. PLoS One. 2016 Jan 19;11(1):e0147119. doi: 10.1371/journal.pone.0147119. eCollection 2016.

Introduction: HIV treatment and disclosure guidelines emphasize the importance of communicating diagnosis and treatment to infected children in ways that are appropriate to children's developmental stage and age. Minimal attention, however, has been given to communication challenges confronted by HIV-infected children and their caregivers. This study examined the tensions between children and their caregivers arising from differing perspectives regarding when and what to communicate about antiretroviral therapy (ART).

Methods: This qualitative study was conducted between November 2011 and December 2012 and involved 29 HIV-infected children aged 8-17 years on ART and their caregivers. Data were collected through observations and in-depth interviews, which took place in homes, treatment centres and post-test clubs. Children and caregivers were sampled from among the 394 HIV-infected children and (their) 393 caregivers who participated in the cross-sectional survey that preceded the qualitative study. ATLAS.ti. Version 7 was used in the management of the qualitative data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis.

Results: While the children felt that they were mature enough to know what they were suffering and what the medications were for, the caregivers wanted to delay discussions relating to the children's HIV diagnosis and medication until they felt that the children were mature enough to deal with the information and keep it a secret and this caused a lot of tension. The children employed different tactics including refusing to take the medicines, to find out what they were suffering from and what the medications were for. Children also had their own ideas about when, where and with whom to discuss their HIV condition, ideas that did not necessarily coincide with those of their caregivers, resulting in tensions.

Conclusions: Guidelines should take into consideration differing perceptions of maturity when recommending ages at which caregivers should communicate with their children about diagnosis and ART. Health care providers should also encourage caregivers to recognize and respect children's efforts to learn about and manage their condition. Children's questions and expressions of feelings should be treated as openings for communication on these issues.

Abstract  Full-text [free] access

Editor’s notes: Caregivers’ ideas of when children are ready to know about their HIV status can often differ from children’s own views. This qualitative study explored children’s and caregivers’ views about HIV status disclosure in the Jinja District in eastern Uganda. A purposive sample of 29 children living with HIV (aged 8-17) was recruited. Participants who were aware of their own HIV status were interviewed (21/29). Great care was taken to avoid accidental disclosure during the study. Caregivers’ views on children’s maturity were not linked to a specific age. Caregivers considered children ‘mature enough’ to know about their status when they believed that children could: 1) understand the implications of their diagnosis; 2) keep secrets 3) take responsibility for their antiretroviral therapy (ART) and 4) begin sexual activity. Some carers thought their child was not mature, but the child saw themselves as being mature enough. Children wanted to know what health condition they had and why they were taking treatment. Children perceived caregivers’ reticence as betrayal. Children deployed strategies such as refusing to take ART or go to the clinic unless they were told what the medication was for. However, children who had been told their status became responsible for their own ART adherence. Older children who were independent often did not discuss HIV or ART with anyone in the household. This could mean they lacked support with adherence issues they might have. The study offers an important and detailed account of the complicated question of disclosure and of communication about HIV and ART in the home. The authors advance our understanding of the importance of age in this process. They highlight the strengths and weaknesses of different approaches to managing adherence in children. The study illustrates the need to improve and extend communication about HIV within and beyond the clinic. The authors highlight that discussions about HIV and ART should be revisited at different points in time to ensure comprehension. This useful paper adds to research exploring children’s agency and resilience strategies in the context of silence and stigma about their HIV status. 

Africa
Uganda
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SMS reminders for HIV treatment adherence had a broader, positive impact on HIV-programme trial participants

The meanings in the messages: how SMS reminders and real-time adherence monitoring improve ART adherence in rural Uganda.

Ware NC, Pisarski EE, Tam M, Wyatt MA, Atukunda E, Musiimenta A, Bangsberg DR, Haberer JE. AIDS. 2016 Jan 23. [Epub ahead of print]

Objective: To understand how a pilot intervention combining SMS reminders with real-time adherence monitoring improved adherence to HIV antiretroviral therapy (ART) for adults initiating treatment in rural Uganda.

Design: Qualitative study, conducted with a pilot randomized controlled trial.

Methods: Sixty-two pilot intervention study participants took part in qualitative interviews on: (a) preferences for content, frequency and timing of SMS adherence reminders; (b) understandings and experiences of SMS reminders; and (c) understandings and experiences of real-time adherence monitoring. Analysis of interview data was inductive and derived categories describing how participants experienced the intervention, and what it meant to them.

Results: SMS reminders prompted taking individual doses of antiretroviral therapy, and helped to develop a "habit" of adherence. Real-time adherence monitoring was experienced as "being seen"; participants interpreted "being seen" as an opportunity to demonstrate seriousness of commitment to treatment and "taking responsibility" for adherence. Both SMS reminders and real-time monitoring were interpreted as signs of "caring" by the health care system. Feeling "cared about" offset depressed mood and invigorated adherence.

Conclusions: While serving as reminders, SMS messages and real-time adherence monitoring also had larger emotional and moral meanings for participants that they felt improved their adherence. Understanding the larger "meanings in the messages," as well as their more literal content and function, will be central in delineating how SMS reminders and other adherence interventions using cellular technology work or do not work in varying contexts.  

Abstract access 

Editor’s notes: SMS reminders have been used in a number of trials in an effort to increase adherence to antiretroviral treatment (ART). The quantitative evidence generally suggests that SMS reminders do not have a significant impact on adherence to ART. However, little is known about why reminders may or may not work for different people in different contexts. This study uses qualitative interviews with trial participants to explore why reminders improved ART adherence in rural Uganda. Participants suggested that the SMS reminders made them “feel seen”, increasing their sense of taking responsibility for adherence. They also felt “cared for” by the health system which offset some negative emotions. This study suggests that SMS reminders may have broader, unmeasured impact on trial participants than simply encouraging adherence. Receiving messages directly from the health care system may have a positive impact on participant morale and attitudes towards trials. 

  
Africa
Uganda
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TB still responsible for large proportion of admissions and in-patient deaths among people living with HIV

TB as a cause of hospitalization and in-hospital mortality among people living with HIV worldwide: a systematic review and meta-analysis.

Ford N, Matteelli A, Shubber Z, Hermans S, Meintjes G, Grinsztejn B, Waldrop G, Kranzer K, Doherty M, Getahun H. J Int AIDS Soc. 2016 Jan 12;19(1):20714. doi: 10.7448/IAS.19.1.20714. eCollection 2016.

Introduction: Despite significant progress in improving access to antiretroviral therapy over the past decade, substantial numbers of people living with HIV (PLHIV) in all regions continue to experience severe illness and require hospitalization. We undertook a global review assessing the proportion of hospitalizations and in-hospital deaths because of tuberculosis (TB) in PLHIV.

Methods: Seven databases were searched to identify studies reporting causes of hospitalizations among PLHIV from 1 January 2007 to 31 January 2015 irrespective of age, geographical region or language. The proportion of hospitalizations and in-hospital mortality attributable to TB was estimated using random effects meta-analysis.

Results: From an initial screen of 9049 records, 66 studies were identified, providing data on 35 845 adults and 2792 children across 42 countries. Overall, 17.7% (95% CI 16.0 to 20.2%) of all adult hospitalizations were because of TB, making it the leading cause of hospitalization overall; the proportion of adult hospitalizations because of TB exceeded 10% in all regions except the European region. Of all paediatric hospitalizations, 10.8% (95% CI 7.6 to 13.9%) were because of TB. There was insufficient data among children for analysis by region. In-hospital mortality attributable to TB was 24.9% (95% CI 19.0 to 30.8%) among adults and 30.1% (95% CI 11.2 to 48.9%) among children.

Discussion: TB remains a leading cause of hospitalization and in-hospital death among adults and children living with HIV worldwide.

Abstract  Full-text [free] access

Editor’s notes: The last 30 years have seen radical improvements in outcomes for many people living with HIV. This study reminds us that in some parts of the world HIV-associated infections, tuberculosis (TB) in particular, still have a devastating effect on thousands of lives.

The importance of TB is widely recognised. WHO aim to reduce deaths due to TB by 75% over the next 10 years.  The question remains: do we really know how many people die due to TB?  Death certification has repeatedly been shown to be unreliable, particularly in the parts of the world where TB is most prevalent. Verbal autopsy is used to estimate cause of death in areas with poor notification systems, but poorly differentiates deaths due to TB and other HIV-associated conditions. Similar challenges are faced when counting and classifying morbidity and hospitalisations. Data are sparse, and determining the cause of an admission is not straightforward, even with access to well-maintained hospital records.  

This review, a sub-analysis of data from a broader study of HIV-associated hospital admissions, is by far the largest of its kind. The authors have been rigorous, given the heterogeneity of the studies included, and their findings are sobering. Among adults living with HIV, in all areas except Europe and South America, TB was the cause of 20-33% of admissions, and some 30% of adults and 45% of children who were admitted with TB were thought to have died from it. These findings are limited by the fact that not all reviewed studies reported on mortality and very few stated how causes of death were assigned.

This paper raises more questions than it answers, but they are important questions.  We are left in no doubt that TB is a major contributor to global morbidity and mortality in HIV-positive people, but we need to look closely at how we count and classify ‘TB deaths’ and ‘TB-associated admissions’. The recent systematic review of autopsy studies cited by the authors also found that almost half the TB seen at autopsy was not diagnosed before death. Global autopsy rates are in decline. Without access to more accurate data, how will we know if we’re winning or losing in our efforts to end TB deaths?

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Depression in people living with HIV – importance of family dynamics

The importance of the family: a longitudinal study of the predictors of depression in HIV patients in South Africa.

Wouters E, Masquillier C, le Roux Booysen F. AIDS Behav. 2016 Jan 18. [Epub ahead of print]

As a chronic illness, HIV/AIDS requires life-long treatment adherence and retention and thus sufficient attention to the psychosocial dimensions of chronic disease care in order to produce favourable antiretroviral treatment (ART) outcomes in a sustainable manner. Given the high prevalence of depression in chronic HIV patients, there is a clear need for further research into the determinants of depression in this population. In order to comprehensively study the predictors of depressive symptoms in HIV patients on ART, the socio-ecological theory postulates to not only incorporate the dominant individual-level and the more recent community-level approaches, but also incorporate the intermediate, but crucial family-level approach. The present study aims to extend the current literature by simultaneously investigating the impact of a wide range individual-level, family-level and community-level determinants of depression in a sample of 435 patients enrolled in the Free State Province of South Africa public-sector ART program. Structural equation modeling is used to explore the relationships between both latent and manifest variables at two time points. Besides a number of individual-level correlates—namely education, internalized and external stigma, and avoidant and seeking social support coping styles—of depressive symptoms in HIV patients on ART, the study also revealed the important role of family functioning in predicting depression. While family attachment emerged as the only factor to continuously and negatively impact depression at both time points, the second dimension of family functioning, changeability, was the only factor to produce a negative cross-lagged effect on depression. The immediate and long-term impact of family functioning on depression draws attention to the role of family dynamics in the mental health of people living with HIV/AIDS. In addition to individual-level and community-based factors, future research activities should also incorporate the role of the family context in research into the mental health of HIV patients, as our results demonstrate that the familial context in which a person with HIV on ART resides is inextricably interconnected with his/her health outcomes.

Abstract access 

Editor’s notes: Effective treatment in the form of antiretroviral therapy now exists for HIV. This means that people living with HIV can have a near-normal life expectancy, provided treatment is started early and adherence to treatment is good. In many settings, including low-income countries, HIV has transitioned from being a terminal illness to a controllable chronic disease. And this brings new challenges for health care providers. As with many chronic illnesses that require lifelong treatment, a diagnosis of HIV can induce depressive symptoms. People living with HIV face a number of additional challenges including stigma, which can impact negatively on mental health. Furthermore, in high HIV prevalence areas people are likely to have witnessed AIDS-related deaths of friends and family. The challenge of providing additional psychosocial care to a growing population of people living with HIV is daunting. This is especially true in resource-poor settings where mental health care services are already stretched. There is a need for research to understand the determinants of depression in order to inform development of appropriate programmes.

This study contributes data on a range of family-level determinants in addition to individual-level and community-level determinants for depression in HIV-positive people. Few studies have focussed on depression in HIV-positive people and the impact of family functioning. Unlike this study, those that have were not conducted in high HIV prevalence, resource-poor settings. The investigators report that family attachment was the only factor that continuously impacted on depression in this population at two different time points. This highlights the role of family dynamics in the mental health and well-being of people living with HIV. Further research that incorporates in-depth qualitative methods is necessary, not only to confirm these findings but to also broaden our understanding of the determinants for depression.  

Africa
South Africa
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Adolescents, safer sex and HIV-status disclosure in South Africa

Sex and secrecy: how HIV-status disclosure affects safe sex among HIV-positive adolescents.

Toska E, Cluver LD, Hodes R, Kidia KK. AIDS Care. 2015 Dec;27 Suppl 1:47-58. doi: 10.1080/09540121.2015.1071775.

HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of one's HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight hundred and fifty eight HIV-positive adolescents (10-19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers. N = 128 (14.9%) of the total sample had ever had sex, while N = 109 (85.1%) of sexually active adolescents had boy/girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partner's status, and 35.5% had disclosed to their partners. For adolescents, knowing one's status was associated with safer sex (OR = 4.355, CI 1.085-17.474, p = .038). Neither knowing their partner's status, nor disclosing one's HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be ill-equipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex.

Abstract  Full-text [free] access

Editor’s notes: Ninety percent of the world’s adolescents living with HIV, live in sub-Saharan Africa.  Evidence illustrates high levels of condomless sex with other adolescents (27-90%) and low rates of disclosure to sexual partners. Negotiating safer sexual practices is particularly challenging for HIV-positive adolescents, exacerbated by HIV-associated factors, learning and accepting their status, and withholding or disclosing their HIV status to sexual partners. There is a dearth of evidence on associations between disclosure and negotiating safer sexual practices among adolescents. This study examines the extent to which disclosure to, and by, adolescents living with HIV is associated with safer sex.

This mixed-methods study employed an iterative approach whereby preliminary qualitative findings guided quantitative measures, particularly items on disclosure. Emerging quantitative findings framed the thematic focus of qualitative research. The study was conducted in the eastern Cape, South Africa. Some 858 adolescents aged 10-19 years were recruited for the quantitative arm of the study. Some 43 participants were included in the qualitative arm of the study. Data generation methods used were individual interviews, focus group discussions and direct observations.

The findings indicate that among adolescents living with HIV, knowledge of HIV-status was strongly associated with safer sex. Knowing one’s partner’s status or disclosing one’s status was not.  Qualitative findings suggest that fear of rejection, exposure, and stigma discouraged HIV-positive adolescents from disclosing to their partners as a strategy for negotiating safer sex. Disclosure counselling and support from healthcare professionals did not address these challenges. Guidelines on counselling HIV-positive adolescents should focus on promoting safer sex with all sexual partners as a first priority, rather than promoting disclosure to sexual partners. Disclosure counselling for HIV-positive adolescents could also be enhanced by improving patient confidentiality, addressing adolescent fears on the dangers of disclosure and by giving HIV-positive adolescents skills to negotiate safer sex.

Africa
South Africa
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Following TB diagnostic algorithms: could do better

What happens after a negative test for tuberculosis? Evaluating adherence to TB diagnostic algorithms in South African primary health clinics.

McCarthy K, Grant AD, Chihota V, Ginindza S, Mvusi L, Churchyard G, Fielding K. J Acquir Immune Defic Syndr. 2015 Nov 25. [Epub ahead of print]

Introduction and background: Diagnostic tests for tuberculosis (TB) using sputum have suboptimal sensitivity among HIV-positive persons. We assessed health care worker adherence to TB diagnostic algorithms after negative sputum test result/s.

Methods: The XTEND trial compared outcomes among people tested for TB in primary care clinics using Xpert® MTB/RIF vs. smear microscopy as the initial test. We analysed data from XTEND participants who were HIV-positive or HIV status unknown, whose initial sputum Xpert® MTB/RIF or microscopy result was negative. If chest radiography, sputum culture or hospital referral took place, the algorithm for TB diagnosis was considered followed. Analysis of intervention (Xpert® MTB/RIF) effect on algorithm adherence used methods for cluster-randomised trials with small number of clusters.

Results: Amongst 4037 XTEND participants with initial negative test results, 2155 (53%) reported being or testing HIV positive and 540 (14%) had unknown HIV status. Amongst 2155 HIV-positive participants (684 [32%] male, mean age 37 years [range 18-79 years]), there was evidence of algorithm adherence amongst 515 (24%). Adherence was less likely among persons tested initially with Xpert® MTB/RIF vs. smear (14% [142/1031] vs 32% [364/1122], adjusted risk ratio 0.34 [95% CI 0.17-0.65]) and for participants with unknown vs. positive HIV status (59/540 [11%] vs. 507/2155 [24%]).

Conclusions: We observed poorer adherence to TB diagnostic algorithms amongst HIV-positive persons tested initially with Xpert® MTB/RIF vs. microscopy. Poor adherence to TB diagnostic algorithms and incomplete coverage of HIV testing represents a missed opportunity to diagnose TB and HIV, and may contribute to TB mortality.

Abstract access

Editor’s notes: Despite advances in the TB diagnostic field in recent years, molecular tests such as Xpert® MTB/RIF will still miss a substantial proportion of HIV-positive people with active TB disease. For that reason, diagnostic algorithms have been developed to guide further evaluation of people with symptoms suggestive of TB who test negative with Xpert®. This paper presents findings from South Africa that, in the context of a cluster-randomised trial, few people received further investigation according to the algorithm.

Only one in seven of the HIV-positive people with a negative Xpert® MTB/RIF had any further investigations recorded. Sputum culture was the most common investigation in this group but was done for only around one in ten. It should be noted that the outcome of having further investigations was largely based on review of clinic and laboratory records. As a result, it is possible that additional investigations were performed but remained undocumented. Although considerable between-clinic variation in performance was noted, the reasons underlying this were not explored in this analysis. The algorithm for people living with HIV was not overly complex and was broadly similar to the algorithm in place previously for investigation of people with a negative sputum smear. The observation that algorithm adherence was lower than for people with a negative smear suggests that health care workers might have had false confidence in the negative Xpert® result. In the broader context, this study took place at a time when there was much hype around Xpert® as a tool that would revolutionise the diagnosis of TB. It would not be surprising if this resulted in health care workers being over-confident in their interpretation of negative test results.

There are other possible explanations for the low numbers having additional investigations:

  • People may not have returned for their initial test result so further investigation was not possible (this is not quantified here)
  • People did return but symptoms had fully resolved or they were unable to produce sputum for further investigation
  • Health care workers used clinical judgement to decide on the need for further investigation rather than adhering strictly to the algorithm. This is supported at least partly by the fact that people with more TB symptoms were more likely to receive additional investigations. The yield of culture is not reported here – that might have given a further clue as to whether the people selected to have further investigations were individuals with a high likelihood of TB.  

These issues and others may need to be explored in future analyses to determine whether modifications to the algorithm are required or whether strengthened training and support of health care workers would improve adherence to the algorithm.

Avoid TB deaths
Africa
South Africa
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Violence experience of women living with HIV: a global study

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

Orza L, Bewley S, Chung C, Crone ET, Nagadya H, Vazquez M, Welbourn A. J Int AIDS Soc. 2015 Dec 1;18(6 Suppl 5):20285. doi: 10.7448/IAS.18.6.20285. eCollection 2015.

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

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

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

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

Abstract  Full-text [free] access

Editor’s notes: Violence against women who are living with HIV is common globally. This paper reports on a study of 832 women living with HIV from 94 countries who participated in an online survey, recruited through a non-random snowball sampling model. The survey comprised quantitative and qualitative (free text) components. Participants included women who had ever or were currently using injection drugs (14%), who had ever or were currently selling sex (14%), and who had ever or were currently homeless (14%). Lifetime experience of violence among respondents was high (86%). Perpetrators included: intimate partner (59%), family member / neighbour (45%), community member (53%), health care workers (53%) and police, military, prison or detention services (17%). Findings suggest that violence is not a one off occurrence and cannot easily be packaged as a cause or a consequence of HIV. Instead violence occurs throughout women’s lives, takes multiple forms, and has a complex and iterative relationship with HIV.

The study population did not represent all women living with HIV, and was biased towards women with internet access who have an activist interest. Nonetheless, the study provides further evidence of the breadth and frequency of gender based violence experienced by women living with HIV. Key recommendations for policy makers include training of health care workers working in sexual and reproductive services to offer non-discriminatory services to women living with HIV and to effectively respond to disclosures of gender based violence (such as intimate partner violence) as part of the package of care.

Algeria, Angola, Argentina, Armenia, Australia, Austria, Azerbaijan, Belarus, Belgium, Belize, Bolivarian Republic of Venezuela, Bolivia, Botswana, Burkina Faso, Burundi, Cambodia, Cameroon, Canada, Chile, China, Colombia, Costa Rica, Côte d'Ivoire, Czech Republic, Democratic Republic of the Congo, Denmark, Dominican Republic, Ecuador, El Salvador, Estonia, Ethiopia, France, Gabon, Germany, Ghana, Greece, Guatemala, Honduras, Hungary, India, Indonesia, Ireland, Italy, Jamaica, Kazakhstan, Kenya, Kyrgyzstan, Lesotho, Malawi, Mali, Mexico, Moldova, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, New Zealand, Nicaragua, Nigeria, Norway, Panama, Paraguay, Peru, Poland, Republic of the Congo, Romania, Russian Federation, Rwanda, Serbia, South Africa, Spain, Sri Lanka, Sudan, Swaziland, Switzerland, Tajikistan, Togo, Transdniestria, Turkey, Uganda, Ukraine, United Kingdom, United Republic of Tanzania, United States of America, Uruguay, Uzbekistan, Viet Nam, Zambia, Zimbabwe
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You’re not a man until you’re a father. Young men’s desire for fatherhood and HIV-associated risk

Fatherhood, marriage and HIV risk among young men in rural Uganda.

Mathur, S, Higgins, J. A, Thummalachetty N, Rasmussen, M, Kelley, L, Nakyanjo, N, Nalugoda, F, Santelli, J. S, Cult Health Sex 2015 Nov 5:1-15 (Epub ahead of print)

Compared to a large body of work on how gender may affect young women’s vulnerability to HIV, we know little about how masculine ideals and practices relating to marriage and fertility desires shape young men’s HIV risk. Using life-history interview data with 30 HIV-positive and HIV-negative young men aged 15–24 years, this analysis offers an in-depth perspective on young men’s transition through adolescence, the desire for fatherhood and experience of sexual partnerships in rural Uganda. Young men consistently reported the desire for fatherhood as a cornerstone of masculinity and transition to adulthood. Ideally young men wanted children within socially sanctioned unions. Yet, most young men were unable to realise their marital intentions. Gendered expectations to be economic providers combined with structural constraints, such as limited access to educational and income-generating opportunities, led some young men to engage in a variety of HIV-risk behaviours. Multiple partnerships and limited condom use were at times an attempt by some young men to attain some part of their aspirations related to fatherhood and marriage. Our findings suggest that young men possess relationship and parenthood aspirations that – in an environment of economic scarcity – may influence HIV-related risk.

Abstract access

Editor’s notes: Gender-specific HIV risks are influenced by biological, social and structural factors. In comparison to factors that affect women’s HIV risk, relatively little is known about how constructions on masculinity affect men’s HIV risk, particularly with relation to young men’s desire for marriage and biological children. In the context meeting fertility ideals, men’s demonstration of masculinity within structural contexts of social change and economic instability, may be associated with certain risk behaviours, including multiple partnerships and inconsistent condom use.

This study utilised data from in-depth life history interviews with 30 HIV-positive and HIV-negative young men aged 15-24 years in southern Uganda. Young men who had acquired bio-medically confirmed HIV over the course of the year between June 2010 and June 2011 and their HIV-negative counterparts were pair-matched by gender, marital status, age and village of residence. The sample included married (n=10), never married (n=16) and previously married men (n=4). Respondents participated in two interviews, approximately two to three weeks apart. Interviews were audio recorded.

Three major themes emerged from the interviews. First, respondents mentioned fatherhood and formal marriage as milestones in the transition to adulthood for young men and a crucial part of the masculine ideal in rural Uganda. Second, truncated educational options and limited economic opportunities made it difficult for young men to acquire formal marriages and fulfil their desires for fatherhood. Third, young men who faced obstacles in trying to achieve these masculine ideals often engaged in alternative strategies, such as condomless sex or having multiple partners, to fulfil their desires for marriage and children; these strategies in turn increased young men’s vulnerability to HIV infection. Regardless of their HIV status young men consistently expressed their desire for marriage and children; described similar economic challenges, and pursued alternative strategies for achieving their masculine ideals. The findings of this study illustrate how the confluence of idealised male masculinities and structural inequalities may play a key role in young men’s vulnerability to HIV.

Africa
Uganda
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Contraception for women on ART – a balancing act

Pregnancy rates in HIV-positive women using contraceptives and efavirenz-based or nevirapine-based antiretroviral therapy in Kenya: a retrospective cohort study.

Patel RC, Onono M, Gandhi M, Blat C, Hagey J, Shade SB, Vittinghoff E, Bukusi EA, Newmann SJ, Cohen CR. Lancet HIV. 2015 Nov;2(11):e474-82. doi: 10.1016/S2352-3018(15)00184-8. Epub 2015 Oct 22.

Background: Concerns have been raised about efavirenz reducing the effectiveness of contraceptive implants. We aimed to establish whether pregnancy rates differ between HIV-positive women who use various contraceptive methods and either efavirenz-based or nevirapine-based antiretroviral therapy (ART) regimens.

Methods: We did this retrospective cohort study of HIV-positive women aged 15-45 years enrolled in 19 HIV care facilities supported by Family AIDS Care and Education Services in western Kenya between Jan 1, 2011, and Dec 31, 2013. Our primary outcome was incident pregnancy diagnosed clinically. The primary exposure was a combination of contraceptive method and efavirenz-based or nevirapine-based ART regimen. We used Poisson models, adjusting for repeated measures, and demographic, behavioural, and clinical factors, to compare pregnancy rates among women receiving different contraceptive and ART combinations.

Findings: 24 560 women contributed 37 635 years of follow-up with 3337 incident pregnancies. In women using implants, adjusted pregnancy incidence was 1.1 per 100 person-years (95% CI 0.72-1.5) for nevirapine-based ART users and 3.3 per 100 person-years (1.8-4.8) for efavirenz-based ART users (adjusted incidence rate ratio [IRR] 3.0, 95% CI 1.3-4.6). In women using depot medroxyprogesterone acetate, adjusted pregnancy incidence was 4.5 per 100 person-years (95% CI 3.7-5.2) for nevirapine-based ART users and 5.4 per 100 person-years (4.0-6.8) for efavirenz-based ART users (adjusted IRR 1.2, 95% CI 0.91-1.5). Women using other contraceptive methods, except for intrauterine devices and permanent methods, had 3.1-4.1 higher rates of pregnancy than did those using implants, with 1.6-2.8 higher rates in women using efavirenz-based ART.

Interpretation: Although HIV-positive women using implants and efavirenz-based ART had a three-times higher risk of contraceptive failure than did those using nevirapine-based ART, these women still had lower contraceptive failure rates than did those receiving all other contraceptive methods except for intrauterine devices and permanent methods. Guidelines for contraceptive and ART combinations should balance the failure rates for each contraceptive method and ART regimen combination against the high effectiveness of implants.

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Editor’s notes: Contraceptive use by women living with HIV who wish to prevent pregnancy remains a key component of the strategy to eliminate new HIV infections among children. Progesterone-based implants are the most effective reversible contraceptive method, but there is some evidence to suggest that their efficacy may be reduced in women receiving efavirenz (EFV)-based antiretroviral therapy (ART).

Overall contraceptive use in these women of childbearing age was low – 70% of the time women were using no contraception or less effective methods only (condoms or natural methods). Overall pregnancy rates were low with the hormonal implant, broadly equivalent to women with intrauterine devices and much lower than with depot injectable and oral contraceptive methods. There was some evidence that the rate of pregnancy in women using the implant was higher for women on EFV-based ART compared to women on nevirapine-based ART. However, the rate of pregnancy remained lower than with injectable or oral contraceptives.

Although this may provide some support to the evidence of reduced implant efficacy with EFV-based ART, it is clear that this can still be an effective contraceptive method. This evidence seems unlikely to change existing WHO recommendations that all forms of contraception should be available to women living with HIV. The low rate of contraceptive use highlights the need to improve access for women living with HIV to quality integrated sexual and reproductive health services. The data from this study suggest that for women wishing to avoid pregnancy, the choice of contraceptive method may be more important than the choice of ART regimen.  

Africa
Kenya
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