Articles tagged as "Stigma and social exclusion"

Young people living with HIV, stigma and its mental health effects

HIV-related stigma, shame, and avoidant coping: risk factors for internalizing symptoms among youth living with HIV?

Bennett DS, Hersh J, Herres J, Foster J. Child Psychiatry Hum Dev. 2016 Aug;47(4):657-64. doi: 10.1007/s10578-015-0599-y.

Youth living with HIV (YLH) are at elevated risk of internalizing symptoms, although there is substantial individual variability in adjustment. We examined perceived HIV-related stigma, shame-proneness, and avoidant coping as risk factors of internalizing symptoms among YLH. Participants (N = 88; ages 12-24) completed self-report measures of these potential risk factors and three domains of internalizing symptoms (depressive, anxiety, and PTSD) during a regularly scheduled HIV clinic visit. Hierarchical regressions were conducted for each internalizing symptoms domain, examining the effects of age, gender, and maternal education (step 1), HIV-related stigma (step 2), shame- and guilt-proneness (step 3), and avoidant coping (step 4). HIV-related stigma, shame-proneness, and avoidant coping were each correlated with greater depressive, anxiety, and PTSD symptoms. Specificity was observed in that shame-proneness, but not guilt-proneness, was associated with greater internalizing symptoms. In multivariable analyses, HIV-related stigma and shame-proneness were each related to greater depressive and PTSD symptoms. Controlling for the effects of HIV-related stigma and shame-proneness, avoidant coping was associated with PTSD symptoms. The current findings highlight the potential importance of HIV-related stigma, shame, and avoidant coping on the adjustment of YLH, as interventions addressing these risk factors could lead to decreased internalizing symptoms among YLH.

Abstract access

Editor’s notes: This study examined the relationship between stigma, shame and avoidant coping strategies and the development of internalizing symptoms, such as anxiety and depression, in young people living with HIV. It is based on researcher-administered questionnaires with 88 young people living with HIV attending an HIV clinic in Philadelphia, USA. The questionnaire included multiple scales to assess. These included young people’s self-reported issues with HIV stigma; tendency to feel shame; tendency to feel guilt; avoidant coping strategies; depressive symptoms; anxiety symptoms; and post-traumatic stress disorder symptoms. Multiple statistical analyses were performed, controlling for the effects of gender, age and maternal education. The study found that HIV-associated stigma, shame and avoidant strategies are risk-factors for the development of depression, anxiety and post-traumatic stress disorder in young people living with HIV. The study provides evidence for the development of psychosocial support that focuses on shame reduction as a way to mediate the impact of stigma on mental health outcomes for young people living with HIV.

Northern America
United States of America
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The negative health impacts of HIV-associated stigma

Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses.

Rueda S, Mitra S, Chen S, Gogolishvili D, Globerman J, Chambers L, Wilson M, Logie CH, Shi Q, Morassaei S, Rourke SB. BMJ Open. 2016 Jul 13;6(7):e011453. doi: 10.1136/bmjopen-2016-011453.

Objective: To conduct a systematic review and series of meta-analyses on the association between HIV-related stigma and health among people living with HIV.

Data sources: A structured search was conducted on 6 electronic databases for journal articles reporting associations between HIV-related stigma and health-related outcomes published between 1996 and 2013.

Study eligibility criteria: Controlled studies, cohort studies, case-control studies and cross-sectional studies in people living with HIV were considered for inclusion.

Outcome measures: Mental health (depressive symptoms, emotional and mental distress, anxiety), quality of life, physical health, social support, adherence to antiretroviral therapy, access to and usage of health/social services and risk behaviours.

Results: 64 studies were included in our meta-analyses. We found significant associations between HIV-related stigma and higher rates of depression, lower social support and lower levels of adherence to antiretroviral medications and access to and usage of health and social services. Weaker relationships were observed between HIV-related stigma and anxiety, quality of life, physical health, emotional and mental distress and sexual risk practices. While risk of bias assessments revealed overall good quality related to how HIV stigma and health outcomes were measured on the included studies, high risk of bias among individual studies was observed in terms of appropriate control for potential confounders. Additional research should focus on elucidating the mechanisms behind the negative relationship between stigma and health to better inform interventions to reduce the impact of stigma on the health and well-being of people with HIV.

Conclusions: This systematic review and series of meta-analyses support the notion that HIV-related stigma has a detrimental impact on a variety of health-related outcomes in people with HIV. This review can inform the development of multifaceted, intersectoral interventions to reduce the impact of HIV-related stigma on the health and well-being of people living with HIV.

Abstract  Full-text [free] access 

Editor’s notes: There is a growing body of research documenting the negative impact of stigma and discrimination on the health of people living with HIV. Stigma is associated with poorer mental health, including emotional distress, depression and reduced psychological functioning. It has also been linked to intermediate health outcomes such as seeking healthcare and adherence to antiretroviral therapy. This paper reports a comprehensive systematic review and meta-analyses summarising the published evidence on the relationship between HIV-associated stigma and a wide range of health outcomes, including intermediate health outcomes. Results illustrate associations between HIV-associated stigma and depressive symptoms, lower levels of social support, ART adherence and use of health services. However, the majority of studies in the review were cross-sectional and longitudinal studies are necessary to explore the complex relationship between these factors, including the role of moderating factors, such as coping strategies. In addition, more research is necessary from low- and middle-income countries given that much of the published research is from North America. Further, there is also a need to better understand the intersection of HIV-associated stigma with other types of stigma experienced by people living with HIV, including homophobia, racism and gender discrimination. 

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Unique needs of gay men in sub-Saharan Africa identified with respondent-driven sampling

Respondent-driven sampling as a recruitment method for men who have sex with men in southern sub-Saharan Africa: a cross-sectional analysis by wave.

Stahlman S, Johnston LG, Yah C, Ketende S, Maziya S, Trapence G, Jumbe V, Sithole B, Mothopeng T, Mnisi Z, Baral S. Sex Transm Infect. 2016 Jun;92(4):292-8. doi: 10.1136/sextrans-2015-052184. Epub 2015 Sep 30.

Objectives: Respondent-driven sampling (RDS) is a popular method for recruiting men who have sex with men (MSM). Our objective is to describe the ability of RDS to reach MSM for HIV testing in three southern African nations.

Methods: Data collected via RDS among MSM in Lesotho (N=318), Swaziland (N=310) and Malawi (N=334) were analysed by wave in order to characterise differences in sample characteristics. Seeds were recruited from MSM-affiliated community-based organisations. Men were interviewed during a single study visit and tested for HIV. X2 tests for trend were used to examine differences in the proportions across wave category.

Results: A maximum of 13-19 recruitment waves were achieved in each study site. The percentage of those who identified as gay/homosexual decreased as waves increased in Lesotho (49% to 27%, p<0.01). In Swaziland and Lesotho, knowledge that anal sex was the riskiest type of sex for HIV transmission decreased across waves (39% to 23%, p<0.05, and 37% to 19%, p<0.05). The percentage of participants who had ever received more than one HIV test decreased across waves in Malawi (31% to 12%, p<0.01). In Lesotho and Malawi, the prevalence of testing positive for HIV decreased across waves (48% to 15%, p<0.01 and 23% to 11%, p<0.05). Among those living with HIV, the proportion of those unaware of their status increased across waves in all study sites although this finding was not statistically significant.

Conclusions: RDS that extends deeper into recruitment waves may be a promising method of reaching MSM with varying levels of HIV prevention needs.

Abstract access  

Editor’s notes: The HIV risk profile of gay men and other men who have sex with men have not been well-characterised within sub-Saharan African countries. These key populations are traditionally difficult to reach for purposes of estimating the prevalence of HIV and of behavioural risk factors, and for prevention outreach. This study enrolled recruiters from community based organizations which served gay men and other men who have sex with men in Malawi, Lesotho and Swaziland. Each of these ‘seeds’ could recruit up to three participants. Each subsequent participant could recruit another three participants into a new ‘wave’. The profiles of participants changed in each setting with each additional recruitment wave. Men in Swaziland were less likely to know that anal sex was the riskiest type of sex, men in Malawi were less likely to have ever tested for HIV, and men in Lesotho were less likely to have disclosed their sexual orientation to family members. This type of respondent-driven sampling can be replicated to identify men who are removed from community-based organisations, and to identify their unique service needs. Future research can consider whether the hardest-to-reach men are also people at highest risk of HIV infection.

Africa
Lesotho, Malawi, Swaziland
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Perceived stigma may lead to increased experienced stigma among people living with HIV

A transactional approach to relationships over time between perceived HIV stigma and the psychological and physical well-being of people with HIV.

Miller CT, Solomon SE, Varni SE, Hodge JJ, Knapp FA, Bunn JY. Soc Sci Med. 2016 Jun 16;162:97-105. doi: 10.1016/j.socscimed.2016.06.025. [Epub ahead of print]

Rationale: Cross-sectional studies demonstrate that perceived discrimination is related to the psychological and physical well-being of stigmatized people. The theoretical and empirical foci of most of this research is on how racial discrimination undermines well-being. The present study takes a transactional approach to examine people with HIV, a potentially concealable stigma.

Hypothesis: The transactional approach posits that even as discrimination adversely affects the psychological well-being of people with HIV, psychological distress also makes them more sensitive to perceiving that they may be or have been stigmatized, and may increase the chances that other people actually do stigmatize them.

Methods: This hypothesis was tested in a longitudinal study in which 216 New England residents with HIV were recruited to complete measures of perceived HIV stigma and well-being across three time points, approximately 90 days apart. This study also expanded on past research by assessing anticipated and internalized stigma as well as perceived discrimination.

Results: Results indicated that all of these aspects of HIV stigma prospectively predicted psychological distress, thriving, and physical well-being. Equally important, psychological distress and thriving also prospectively predicted all three aspects of HIV stigma, but physical well-being did not.

Conclusion: These findings suggest that people with HIV are ensnared in a cycle in which experiences of stigma and reduced psychological well-being mutually reinforce each other.

Abstract access

Editor’s notes: Stigma can act as a barrier to the delivery and uptake of HIV care. This study investigated the transactional approach to understanding stigma. The authors sought to determine whether psychological stress due to perceptions of discrimination causes people living with HIV to be more sensitive to perceiving stigma. Then in turn whether this makes it more likely that they will be stigmatized. The authors examined data from a longitudinal study of 216 participants in New England in the United States. The study was embedded within a larger study protocol that sought to answer a broad range of research questions. Participants responded to a questionnaire which asked questions about participants’ perceived stigma based on the HIV Stigma Scale developed by Berger and colleagues in 2001. The authors used three subscales to measure enacted, anticipated, and internalized stigma. Participants responded to questions on a 5-point subscale of strongly disagree (scored as 1) to strongly agree (scored as 5) to questions about the three different types of stigma. The authors analysed associations between perceived, internalized, and experienced stigma. The authors concluded that understanding the transactional relationship between HIV-associated stigma and psychological stress is important for developing and implementing effective HIV-associated stigma programmes. Perceptions of stigma may lead to increases in perceived and experienced stigma among people living with HIV. This study suggests that future programmes that seek to address HIV-associated stigma should incorporate an understanding of the transactional relationship between psychological stress and perceived and experienced stigma.

Northern America
United States of America
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Routine programmatic data used to estimate HIV incidence and service uptake among female sex workers in Zimbabwe

Implementation and operational research: cohort analysis of program data to estimate HIV incidence and uptake of HIV-related services among female sex workers in Zimbabwe, 2009-2014.

Hargreaves JR, Mtetwa S, Davey C, Dirawo J, Chidiya S, Benedikt C, Naperiela Mavedzenge S, Wong-Gruenwald R, Hanisch D, Magure T, Mugurungi O, Cowan FM. J Acquir Immune Defic Syndr. 2016 May 1;72(1):e1-8. doi: 10.1097/QAI.0000000000000920.

Background: HIV epidemiology and intervention uptake among female sex workers (FSW) in sub-Saharan Africa remain poorly understood. Data from outreach programs are a neglected resource.

Methods: Analysis of data from FSW consultations with Zimbabwe's National Sex Work program, 2009-2014. At each visit, data were collected on sociodemographic characteristics, HIV testing history, HIV tests conducted by the program and antiretroviral (ARV) history. Characteristics at first visit and longitudinal data on program engagement, repeat HIV testing, and HIV seroconversion were analyzed using a cohort approach.

Results: Data were available for 13 360 women, 31 389 visits, 14 579 reported HIV tests, 2750 tests undertaken by the program, and 2387 reported ARV treatment initiations. At first visit, 72% of FSW had tested for HIV; 50% of these reported being HIV positive. Among HIV-positive women, 41% reported being on ARV. 56% of FSW attended the program only once. FSW who had not previously had an HIV-positive test had been tested within the last 6 months 27% of the time during follow-up. After testing HIV positive, women started on ARV at a rate of 23/100 person years of follow-up. Among those with 2 or more HIV tests, the HIV seroconversion rate was 9.8/100 person years of follow-up (95% confidence interval: 7.1 to 15.9).

Conclusions: Individual-level outreach program data can be used to estimate HIV incidence and intervention uptake among FSW in Zimbabwe. Current data suggest very high HIV prevalence and incidence among this group and help identify areas for program improvement. Further methodological validation is required.

Abstract access

Editor’s notes: Female sex workers in resource poor regions have been shown to have higher levels of HIV incidence and prevalence than people in the general population. Due to the highly stigmatised and often illegal nature of their work, these individuals are often marginalised in society. This can lead to poor engagement with the HIV testing and treatment programmes provided for the general population. Targeted outreach programmes for female sex workers such as the “Sisters for Change” programme in Zimbabwe described in this paper, aim to improve the engagement with testing and care for this group.

Collecting reliable data from female sex workers using a convenience sampling approach in order to estimate the prevalence of HIV is challenging due to the difficulty in ensuring the survey sample is representative of the wider female sex worker population. An alternative approach is respondent driven sampling (RDS) in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations. The results from RDS are however complex to analyse and interpret.

This paper presents an alternative approach using routinely collected data. Using the dates of programme visits, HIV tests (conducted both within and outside of the programme) and dates of antiretroviral initiation, the researchers generated estimates of HIV prevalence (number of positive tests/total number of tests) and HIV incidence (time at risk calculated from the first visit to an imputed date of seroconversion). They also identified risk factors associated with socio-demographic parameters or HIV testing history that were associated with a failure to continue engagement with the programme after a first visit. The prevalence and incidence results are consistent with results from a series of RDS surveys previously conducted in Zimbabwe by this research team.

A difficulty highlighted by the authors is that while this method improves on convenience sampling, it is still difficult to know how HIV incidence and prevalence among programme participants compares to that in the wider female sex worker population. 

In summary this paper presents an approach by which similar programmes elsewhere could make better use of routinely collected data in order to generate estimates of impact and also identify sub-groups of female sex workers with poorer engagement with care. This in turn could lead to a more effective targeting of limited resources.

Africa
Zimbabwe
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Finding out at home: community members’ and healthcare workers’ views on the use of oral HIV self-testing in Kayelitsha, South Africa

'I know that I do have HIV but nobody saw me': oral HIV self-testing in an informal settlement in South Africa.

Martinez Perez G, Cox V, Ellman T, Moore A, Patten G, Shroufi A, Stinson K, Van Cutsem G, Ibeto M. PLoS One. 2016 Apr 4;11(4):e0152653. doi: 10.1371/journal.pone.0152653. eCollection 2016.

Reaching universal HIV-status awareness is crucial to ensure all HIV-infected patients access antiretroviral treatment (ART) and achieve virological suppression. Opportunities for HIV testing could be enhanced by offering self-testing in populations that fear stigma and discrimination when accessing conventional HIV Counselling and Testing (HCT) in health care facilities. This qualitative research aims to examine the feasibility and acceptability of unsupervised oral self-testing for home use in an informal settlement of South Africa. Eleven in-depth interviews, two couple interviews, and two focus group discussions were conducted with seven healthcare workers and thirteen community members. Thematic analysis was done concurrently with data collection. Acceptability to offer home self-testing was demonstrated in this research. Home self-testing might help this population overcome barriers to accepting HCT; this was particularly expressed in the male and youth groups. Nevertheless, pilot interventions must provide evidence of potential harm related to home self-testing, intensify efforts to offer quality counselling, and ensure linkage to HIV/ART-care following a positive self-test result.

 Abstract Full-text [free] access

Editor’s notes: This is a qualitative study with services users and healthcare workers from an HIV testing service ran by Médecins Sans Frontières (MSF) in Kayelitsha, South Africa. Couple and individual interviews and focus group discussions were conducted with 20 people. The participants discussed preferences of types of HIV testing and acceptability of HIV home-testing. The aim was to inform the pilot of an activity for the use of an oral HIV self-testing device (OraQuick). OraQuick is self-administered as an oral swab and gives results straightaway. The study sample included people who had previously refused an HIV test in the clinic, people who had received an HIV test in the clinic and agreed to a couple interview with their partners. Key reasons for refusing an HIV test in the clinic included: fear of finding out one’s status, fear of HIV-treated discrimination and concerns about confidentiality in testing services. Clinics were seen by male participants as ‘women’s places’.  Men thought visiting a service for an HIV test could harm one’s reputation. Home-testing was seen as preferable because it afforded more privacy. However, not wanting to know one’s status remains a barrier even with home-testing. There were concerns that partners (of both sexes) could pressure one another to test with OraQuick and tensions could arise in case of serodiscordant results. There were concerns that some users could get confused by a test that detects the presence of HIV in the mouth. This would contradict current awareness that HIV cannot be passed through kissing. False-negative tests could encourage unsafe sex. Participants worried that some people may not link into care and treatment after finding out they are HIV positive with a home-test. The study concludes that home-testing could reach populations (especially male partners of women living with HIV and young people) that do not come forward for testing through other services, including clinic-based and voluntary community testing. Many of the disadvantages of home-testing could be mitigated with appropriate education and pre-test counselling. The pilot study continues.  It is expected that the study will be able to address questions of linkage to care for people who test HIV-positive. 

Africa
South Africa
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Comparing the performance of different community-based measures of viral load as correlates for HIV incidence

Community viral load, antiretroviral therapy coverage, and HIV incidence in India: a cross-sectional, comparative study.

Solomon SS, Mehta SH, McFall AM, Srikrishnan AK, Saravanan S, Laeyendecker O, Balakrishnan P, Celentano DD, Solomon S, Lucas GM. Lancet HIV. 2016 Apr;3(4):e183-90. doi: 10.1016/S2352-3018(16)00019-9. Epub 2016 Mar 11.

Background: HIV incidence is the best measure of treatment-programme effectiveness, but its measurement is difficult and expensive. The concept of community viral load as a modifiable driver of new HIV infections has attracted substantial attention. We set out to compare several measures of community viral load and antiretroviral therapy (ART) coverage as correlates of HIV incidence in high-risk populations.

Methods: We analysed data from a sample of people who inject drugs and men who have sex with men, who were participants of the baseline assessment of a cluster-randomised trial in progress across 22 cities in India (ClinicalTrials.gov number NCT01686750). We recruited the study population by use of respondent-driven sampling and did the baseline assessment at 27 community-based sites (12 for men who have sex with men and 15 for people who inject drugs). We estimated HIV incidence with a multiassay algorithm and calculated five community-based measures of HIV control: mean log10 HIV RNA in participants with HIV in a community either engaged in care (in-care viral load), aware of their status but not necessarily in care (aware viral load), or all HIV-positive individuals whether they were aware, in care, or not (population viral load); participants with HIV in a community with HIV RNA more than 150 copies per mL (prevalence of viraemia); and the proportion of participants with HIV who self-reported ART use in the previous 30 days (population ART coverage). All participants were tested for HIV, with additional testing in HIV-positive individuals. We assessed correlations between the measures and HIV incidence with Spearman correlation coefficients and linear regression analysis.

Findings: Between Oct 1, 2012, and Dec 19, 2013, we recruited 26 503 participants, 12 022 men who have sex with men and 14 481 people who inject drugs. Median incidence of HIV was 0.87% (IQR 0.40-1.17) in men who have sex with men and 1.43% (0.60-4.00) in people who inject drugs. Prevalence of viraemia was more strongly correlated with HIV incidence (correlation 0.81, 95% CI 0.62-0.91; p<0.0001) than all other measures, although correlation was significant with aware viral load (0.59, 0.27-0.79; p=0.001), population viral load (0.51, 0.16-0.74; p=0.007), and population ART coverage (-0.54, -0.76 to -0.20; p=0.004). In-care viral load was not correlated with HIV incidence (0.29, -0.10 to 0.60; p=0.14). With regression analysis, we estimated that to reduce HIV incidence by 1 percentage point in a community, prevalence of viraemia would need to be reduced by 4.34%, and ART use in HIV-positive individuals would need to increase by 19.5%.

Interpretation: Prevalence of viraemia had the strongest correlation with HIV incidence in this sample and might be a useful measure of the effectiveness of a treatment programme.

Abstract access    

Editor’s notes: The ideal metric of impact for a programme looking at the prevention benefits of treatment would be the reduction in HIV incidence in the target population. Incidence is however very difficult to measure. ‘Community viral load’ has been proposed as an alternative. However its estimation using data collected either in a routine clinical setting or from a cohort study can suffer from bias, due to the population included not being representative of the wider population of people living with HIV.

This paper describes a study among gay men and other men who have sex with men and people who inject drugs carried out at 27 sites in India. Participants were recruited using respondent-driven sampling (in which respondents recruit their peers to produce a generally representative sample of hard-to-reach populations). At each site incidence was estimated using a multi-assay algorithm designed to identify seroconversion occurring approximately within the last six months. Five community-based measures of viral load were measured at each site. Of these, the prevalence of HIV viraemia (i.e. the proportion of the population with a viral load greater than 150 copies per mL), was most strongly associated with HIV incidence, while mean viral load among people in-care was not associated. This latter finding is important if a case-based surveillance approach using only data collected at clinics is to be used to estimate incidence. Population ART coverage, a measure of the proportion of the site participants on ART was also strongly correlated with incidence. As this can be measured through a simple questionnaire, rather than lab-based assays, it could be an easily and cheaply obtainable correlate for incidence, albeit one potentially prone to response bias.

Asia
India
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The right kind of sex

The feminine ideal and transactional sex: navigating respectability and risk in Swaziland.

Fielding-Miller R, Dunkle KL, Jama-Shai N, Windle M, Hadley C, Cooper HL. Soc Sci Med. 2016 Apr 7;158:24-33. doi: 10.1016/j.socscimed.2016.04.005. [Epub ahead of print]

Women who engage in transactional sex are not only at increased risk of HIV and intimate partner violence, but also face social risks including gossip and ostracism. These social and physical risks may be dependent on both what a woman expects and needs from her partner and how her community perceives the relationship. Gender theory suggests that some of these social risks may hinge on whether or not a woman's relationship threatens dominant masculinity. We conducted a qualitative study in Swaziland from September 2013 to October 2014 to explore transactional sex and respectable femininity through the lens of hegemonic gender theory. Using cultural consensus modeling, we identified cultural models of transactional sex and conducted 16 in-depth interviews with model key informants and 3 focus group discussions, for a total of 41 participants. We identified 4 main models of transactional relationships: One typified by marriage and high social respectability, a second in which women aspire towards marriage, a third particular to University students, and a fourth "sugar daddy" model. Women in all models expected and received significant financial support from their male partners. However, women in less respectable relationships risked social censure and stigma if they were discovered, in part because aspects of their relationship threatened hegemonic masculinity. Conversely, women who received male support in respectable relationships had to carefully select HIV risk reduction strategies that did not threaten their relationship and associated social status. Research and programming efforts typically focus only on the less socially respectable forms of transactional sex. This risks reinforcing stigma for women in relationships that are already considered socially unacceptable while ignoring the unique HIV risks faced by women in more respectable relationships.

Abstract access

Editor’s notes: Adolescent girls and young women are at a disproportionate risk of HIV infection when compared to their male counterparts. Transactional sex is associated with gendered HIV vulnerability in sub-Saharan Africa and is also associated with intimate partner violence. While economic exchange is present in many relationships, adolescent girls and young women are required to navigate a line between acceptable and unacceptable economic dependence. This line is further complicated by the fact that in much of the world, the notion of ‘men as providers’ is considered the norm. 

The findings illustrate, as with previous research, that women’s economic dependence in relationships was seen to be a risk. So too was social pressure. Women whose relationships manifested an emphasised femininity used health protection strategies that did not jeopardise their relationship (for example always being sexually available) so as to maintain their social and economic stability. Health protection strategies of women, whose relationship was deemed less acceptable, were more mixed.  They may have been less able to negotiate condom use or sexual encounters if they were financially dependent on their partners. But they may also have been more willing to leave a partner or demand condom use. Women who were ‘too independent’ were condemned and stigmatised by community members because of their threat to male dominance.  Programmes designed to reduce risk associated with transactional sex may have greater impact if they focus on the power dynamics created by gender norms. This may be more effective than focusing on the exchange of gifts or money within a relationship. It is important to pay careful attention to local understandings and interpretation of women’s financial, sexual and romantic obligations. We also need to understand women’s motivations for entering or remaining in sexual relationships.

Africa
Swaziland
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Mobility, migration, and HIV: not always what you assume

The Silk Road health project: how mobility and migration status influence HIV risks among male migrant workers in central Asia. 

El-Bassel N, Gilbert L, Shaw SA, Mergenova G, Terlikbayeva A, Primbetova S, Ma X, Chang M, Ismayilova L, Hunt T, West B, Wu E, Beyrer C. PLoS One. 2016 Mar 11;11(3):e0151278. doi: 10.1371/journal.pone.0151278. eCollection 2016.

Objectives: We examined whether mobility, migrant status, and risk environments are associated with sexually transmitted infections (STIs) and HIV risk behaviors (e.g. sex trading, multiple partners, and unprotected sex).

Methods: We used Respondent Driven Sampling (RDS) to recruit external male migrant market vendors from Kyrgyzstan, Uzbekistan, and Tajikistan as well internal migrant and non-migrant market vendors from Kazakhstan. We conducted multivariate logistic regressions to examine the effects of mobility combined with the interaction between mobility and migration status on STIs and sexual risk behaviors, when controlling for risk environment characteristics.

Results: Mobility was associated with increased risk for biologically-confirmed STIs, sex trading, and unprotected sex among non-migrants, but not among internal or external migrants. Condom use rates were low among all three groups, particularly external migrants. Risk environment factors of low-income status, debt, homelessness, and limited access to medical care were associated with unprotected sex among external migrants.

Conclusion: Study findings underscore the role mobility and risk environments play in shaping HIV/STI risks. They highlight the need to consider mobility in the context of migration status and other risk environment factors in developing effective prevention strategies for this population.

Abstract  Full-text [free] access 

Editor’s notes: The 14 participants selected as seeds in this respondent driven sampling (RDS) strategy generated two large chains that made up 90% of the recruited study sample of 1324 male labour market workers at the Baraholka Market in Almaty, Kazakhstan. An estimated one million labour migrants enter Kazakhstan each year from neighbouring Central Asian countries that lack employment opportunities. However they face stigma, discrimination, police harassment, and lack of access to services. Finding out whether they are resilient to risk of exposure to HIV and other sexually transmitted infections (STIs) or are more likely to acquire HIV/STIs is key to designing effective HIV prevention strategies in a country that saw HIV incidence rise 25% between 2001 and 2009. This study looked at associations between HIV and STI risk and mobility – defined as having travelled outside Almaty in the last 90 days. The study was among three groups at the market: external migrants, internal migrants, and non-migrants. The analysis adjusted for both sociodemographic and-structural risk environment factors (legal status, income, debt, policing, homelessness, loneliness, social support, access to medical care, and alcohol use). Overall, 5.2% were positive for any STI. These included 2.1% of external migrants, 7.5% of internal migrants, and 8.8% of non-migrants. The authors hypothesise that mobility was not associated with increased STIs and a range of risk behaviours in external and internal migrants because these men travel primarily to visit their families and because they are goal-oriented and focused on fulfilling their roles as major wage earners for their families. These findings are in contrast to those of other studies that suggest that migrants are at higher HIV risk and challenge perceptions of migrants as a source of disease transmission within host countries. They underscore the importance of prevention strategies in unique venues such as markets, including peer-led prevention messaging, mobile clinics, and confidential HIV/STI testing. However, to address the factors that put migrants at risk for HIV, the authors argue for labour agreements, a legal registration process, and other measures to sustain their rights, prevent violence against migrants, and reduce marginalisation. 

Asia
Kazakhstan
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An innovative method to evaluate community support for children: Using existing datasets

How effective is help on the doorstep? A longitudinal evaluation of community-based organisation support. 

Sherr L, Yakubovich AR, Skeen S, Cluver LD, Hensels IS, Macedo A, Tomlinson M. PLoS One. 2016 Mar 11;11(3):e0151305. doi: 10.1371/journal.pone.0151305. eCollection 2016.

Community-based responses have a lengthy history. The ravages of HIV on family functioning has included a widespread community response. Although much funding has been invested in front line community-based organisations (CBO), there was no equal investment in evaluations. This study was set up to compare children aged 9-13 years old, randomly sampled from two South African provinces, who had not received CBO support over time (YC) with a group of similarly aged children who were CBO attenders (CCC). YC baseline refusal rate was 2.5% and retention rate was 97%. CCC baseline refusal rate was 0.7% and retention rate was 86.5%. 1848 children were included—446 CBO attenders compared to 1402 9-13 year olds drawn from a random sample of high-HIV prevalence areas. Data were gathered at baseline and 12-15 months follow-up. Standardised measures recorded demographics, violence and abuse, mental health, social and educational factors. Multivariate regression analyses revealed that children attending CBOs had lower odds of experiencing weekly domestic conflict between adults in their home (OR 0.17; 95% CI 0.09, 0.32), domestic violence (OR 0.22; 95% CI 0.08, 0.62), or abuse (OR 0.11; 95% CI 0.05, 0.25) at follow-up compared to participants without CBO contact. CBO attenders had lower odds of suicidal ideation (OR 0.41; 95% CI 0.18, 0.91), fewer depressive symptoms (B = -0.40; 95% CI -0.62, -0.17), less perceived stigma (B = -0.37; 95% CI -0.57, -0.18), fewer peer problems (B = -1.08; 95% CI -1.29, -0.86) and fewer conduct problems (B = -0.77; 95% CI -0.95, -0.60) at follow-up. In addition, CBO contact was associated with more prosocial behaviours at follow-up (B = 1.40; 95% CI 1.13, 1.67). No associations were observed between CBO contact and parental praise or post-traumatic symptoms. These results suggest that CBO exposure is associated with behavioural and mental health benefits for children over time. More severe psychopathology was not affected by attendance and may need more specialised input.

Abstract  Full-text [free] access 

Editor’s notes: This study is novel in both its research question and its methodology. The study aims to assess whether receipt of support from community-based organisations (CBOs) impacts the mental and social well-being of children in high HIV prevalence areas. The CBOs studied include many different organisations with diverse services, giving the study the benefit of assessing the overall impact of a combination of small, motivated groups. This helps lend credibility to CBOs and to convince policymakers and funders to support small-scale CBOs.

In terms of methodology, the study utilises two longitudinal datasets from southern Africa to explore the study aims. One survey is from a study of children affected by HIV served by CBOs, while the other is from a study of children affect by HIV without CBO support. There are some limitations to using two different studies, most especially unclear comparability and, in this case, lack of control data to adjust for possible differences, for example on socio-economic status or how HIV specifically affected the child. Despite these, this paper has striking results, and is an innovative effort to improve our understanding of the impact of CBOs on children’s well-being and should spur further creativity in impact evaluation methods.

Africa
South Africa
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