Articles tagged as "Stigma and social exclusion"

Programme planning must take into account diversity of sex worker populations - Pakistan

Heterogeneity among sex workers in overlapping HIV risk interactions with people who inject drugs: a cross-sectional study from 8 major cities in Pakistan. 

Melesse DY, Shafer LA, Shaw SY, Thompson LH, Achakzai BK, Furqan S, Reza T, Emmanuel F, Blanchard JF. Medicine (Baltimore). 2016 Mar;95(12):e3085. doi: 10.1097/MD.0000000000003085.

Concerns remain regarding the heterogeneity in overlapping human immunodeficiency virus (HIV) risk behaviors among sex workers (SWs) in Pakistan; specifically, the degree to which SWs interact with people who inject drugs (PWID) through sex and/or needle sharing. Following an in-depth mapping performed in 2011 to determine the size and distribution of key populations at highest risk of HIV acquisition in Pakistan, a cross-sectional biological and behavioral survey was conducted among PWID, female (FSWs), male (MSWs), and hijra/transgender (HSWs) sex workers, and data from 8 major cities were used for analyses. Logistic regression was used to identify factors, including city of residence and mode of SW-client solicitation, contributing to the overlapping risks of drug injection and sexual interaction with PWID. The study comprised 8483 SWs (34.5% FSWs, 32.4% HSWs, and 33.1% MSWs). Among SWs who had sex with PWID, HSWs were 2.61 (95% confidence interval [CI], 1.19-5.74) and 1.99 (95% CI, 0.94-4.22) times more likely to inject drugs than MSWs and FSWs, respectively. There was up to a 3-fold difference in drug injecting probability, dependent on where and/or how the SW solicited clients. Compared with SWs in Larkana, the highest likelihood of drug injection use was among SWs in Multan (OR = 4.52; 95% CI: 3.27-6.26), followed by those in Lahore, Quetta, and Faisalabad. Heterogeneity exists in the overlapping patterns of HIV risk behaviors of SWs. The risk of drug injection among SWs also varies by city. Some means of sexual client solicitation may be along the pathway to overlapping HIV risk vulnerability due to increased likelihood of drug injection among SWs. There is a need to closely monitor the mixing patterns between SWs and PWID and underlying structural factors, such as means of sexual client solicitation, that mediate HIV risk, and implement prevention programs customized to local sub-epidemics.

Abstract  Full-text [free] access

Editor’s notes: This is an important paper reporting findings of an HIV prevalence and risk behaviour survey among sex workers and people who inject drugs. The paper describes the diversity of sex work, including male and transgender sex workers that are often neglected in research and service planning. It also examines injecting drug use among sex workers, a behaviour that can increase sex workers’ vulnerability to HIV, violence and other health harms. The finding that among sex workers who had a sex partner who also injected drugs, transgender sex workers had higher odds of injecting than male or female sex workers is important. This finding highlights the differences in vulnerability among the three sex worker populations, whose diversity is often not taken into account in programme planning. Other international evidence suggests increased stigma experienced by transgender sex workers on account of their gender. For example, with increased arrest and harassment administered by police and higher levels of poor emotional health. These are factors that might explain use of injecting drugs as a coping strategy. The study illustrates a clear need to target harm reduction services among this population, to ensure they have access to needle-syringe programmes.  Advice on safe injecting practices and how to manage injecting drug use alongside sex work are also necessary. Findings also clearly illustrate the need to understand better the underlying determinants of drug use and address those. Understanding why prevalence of drug use varies by city is vital. So too, is understanding how the way in which clients are engaged increases risk of injecting, in order to create enabling environments to minimise harms associated with injecting. 

Asia
Pakistan
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Fear of HIV test deters Ethiopians from getting malaria treatment

Concerns about covert HIV testing are associated with delayed presentation in Ethiopian adults with suspected malaria: a cross-sectional study.

Tadesse F, Deressa W, Fogarty AW. BMC Public Health. 2016 Feb 1;16(1):102. doi: 10.1186/s12889-016-2773-y

Background: Although early diagnosis and prompt treatment is important in preventing mortality from malaria, presentation of symptomatic individuals is often relatively late. One possible contributing factor is that fear of covert human immunodeficiency virus (HIV) testing delays presentation in adults. We aimed to survey the magnitude of such concerns and their association with delayed presentation with suspected malaria.

Methods: The study design was a health facility-based cross-sectional survey. The study population consisted of adults with suspected malaria who presented to health centres in central Ethiopia. Data were collected on attitudes to HIV testing and the duration between onset of symptoms and treatment seeking for suspected malaria.

Results: Eight hundred and ten individuals provided data. Of these, 406 (50 %) perceived that HIV testing was routinely done on blood donated for malaria diagnosis, and 327 (40 %) considered that community members delayed seeking medical advice because of these concerns. Concerns about HIV testing were associated with delays in attending for malaria diagnosis and treatment, with 117 individuals (29 %) of those with concerns about covert HIV testing waiting for 4 days or more, compared to 89 (22 %) of those who did not have any such concerns (p = 0.03). One hundred and twenty nine (16 %) individuals stated that concern about HIV testing was the main reason for the delay in seeking treatment, and 46 % of these individuals presented after experiencing symptoms of malaria infection for three days or more compared to 22 % of the 681 individuals who had no such concerns (p < 0.001). Analysis stratified by health centre demonstrated that these associations were a consequence of Meki health centre (odds ratio for duration of symptoms greater than 3 days if patient has concerns about HIV testing was 8.72; 95 % confidence intervals 3.63 to 20.97).

Conclusions: In adults living in central Ethiopia, the perception that HIV testing accompanied the investigation of suspected malaria was common. This is likely to impede presentation for early medical treatment in some areas and represents a reversible risk factor that deserves further study.

Abstract  Full-text [free] access 

Editor’s notes: This study addresses a relatively under-studied issue of concerns about HIV testing among adults with malaria. Previously, the authors of this paper found that about half of guardians of children with malaria symptoms in central Ethiopia thought the children’s blood samples were tested for HIV without consent. Guardians who believed this were more likely to delay bringing children for treatment. In this paper, the authors illustrate that the same is true for adults. In a representative survey of adults presenting with malaria symptoms at five health centres, about half of participants were concerned that their blood sample was secretly tested for HIV without their consent and about one in three thought that many or almost all members of their community believed this. Concern about covert HIV testing was associated with delayed presentation for management of suspected malaria overall, although this was largely due to the issue in one specific health centre. Electricity in the home, better education and urban versus rural home were not associated with this belief, although people in rural areas were more likely to delay treatment-seeking.

Beliefs about health care are culturally specific, so the results may not be generalizable to other contexts, but the belief that blood taken at health centres is secretly tested for HIV has been found in different cultural settings. Prompt treatment for suspected malaria is key and strategies to address these concerns are necessary. Possible strategies include investigations to clarify whether, in fact, blood is being tested for HIV without fully informed consent, and improved confidentiality of blood test results. 

Africa
Ethiopia
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Understanding barriers and facilitators to uptake and adherence of ART under Option B+ in Lilongwe, Malawi

Why did I stop? Barriers and facilitators to uptake and adherence to ART in option B+ HIV care in Lilongwe, Malawi.

Kim MH, Zhou A, Mazenga A, Ahmed S, Markham C, Zomba G, Simon K, Kazembe PN, Abrams EJ. PLoS One. 2016 Feb 22;11(2):e0149527. doi: 10.1371/journal.pone.0149527. eCollection 2016.

Causes for loss-to-follow-up, including early refusals of and stopping antiretroviral therapy (ART), in Malawi's Option B+ program are poorly understood. This study examines the main barriers and facilitators to uptake and adherence to ART under Option B+. In depth interviews were conducted with HIV-infected women who were pregnant or postpartum in Lilongwe, Malawi (N = 65). Study participants included women who refused ART initiation (N = 10), initiated ART and then stopped (N = 26), and those who initiated ART and remained on treatment (N = 29). The barriers to ART initiation were varied and included concerns about partner support, feeling healthy, and needing time to think. The main reasons for stopping ART included side effects and lack of partner support. A substantial number of women started ART after initially refusing or stopping ART. There were several facilitators for re-starting ART, including encouragement from community health workers, side effects subsiding, decline in health, change in partner, and fear of future sickness. Amongst those who remained on ART, desire to prevent transmission and improve health were the most influential facilitators. Reasons for refusing and stopping ART were varied. ART-related side effects and feeling healthy were common barriers to ART initiation and adherence. Providing consistent pre-ART counseling, early support for patients experiencing side effects, and targeted efforts to bring women who stop treatment back into care may improve long term health outcomes.

Abstract  Full-text [free] access 

Editor’s notes: Option B+ is a policy recommendation of World Health Organisation (WHO) that offers all pregnant and breast-feeding women living with HIV, life-long antiretroviral therapy (ART), regardless of CD4 count or clinical stage. Few studies have examined the challenges faced by pregnant and breast-feeding women, as they navigate the prevention of mother-to-child transmission cascade. The objective of this study was to identify the main barriers and facilitators to uptake and adherence to ART under Option B+ in Lilongwe, Malawi. This was done by conducting qualitative interviews (n=65) with women living with HIV who were pregnant or post-partum and had initiated ART, and women who refused or had stopped treatment.

The most important facilitator for initially starting and remaining on ART was the need to prevent transmission to their infants and to maintain health (prevent illness). Furthermore, ART was viewed as a solution to women’s health issues. This was especially the case when women believed that their health problems were associated with their HIV infection. There were a number of reasons that emerged for refusing ART. For most women the urgency of having to initiate ART under Option B+ was a major challenge. Women felt that they needed time, either to discuss their status with their partner or to accept their own status. In particular, the desire to speak to their partners emerged quite prominently reflecting a fear of disclosure and concern about their partner’s reaction. Another reason was generally feeling healthy before initiating treatment. Women wanted to wait until their health declined before initiating treatment. Religious beliefs did not play a significant role for most women. Only one woman refused because she believed that God, not healthcare providers, would tell her when she needed to start treatment. Side effects were the most commonly reported reason for stopping ART. Half of the 26 (N = 13) respondents who stopped ART did so because they experienced side effects, which included dizziness, nausea or vomiting, nightmares and hallucinations (9%). Women who had side effects also expressed challenges with food security. Side effects made some women question the efficacy of ART. The lack of partner support was another important barrier to ART adherence as women reported fear of disclosing their status to their husbands. Interestingly, although partner support was factored into women’s decision making, in most cases it was not the main consideration. The majority of partners (n=44) accepted their wives’ status, often sending reminders to take ART every night. However, many women did not return to the clinic even though their partners accepted their status (N = 17). One woman, for instance, took the money her husband gave her for transport to the clinic and spent it on other things. Forgetting to take pills or losing pills were other reasons given for lack of adherence. Stigma within the community was acknowledged as an issue, but there were few reports of overt discrimination. Further, even though some women refused or stopped ART, many of them re-started for reasons such as, feeling encouraged by a community health worker (CHW) or someone like a CHW. This was through their monthly home visits to check on women’s use of ART and to provide treatment support such as explaining the side-effects, counselling husbands and encouraging women to re-start. Decline in health, fear of future sickness, as well as reduction in side-effects were mentioned as reasons for re-starting on ART.

Overall, study authors mention that in the context of Option B+, inadequate time in preparing to initiate ART, as well as side effects emerged as more significant barriers as compared to previous studies on barriers and facilitators in non-Option B+ contexts. Economic barriers to care did not emerge as very significant in this study when comparted to other studies; however, a lack of food affects the severity of side effects. This suggests that economic barriers may manifest as an indirect mechanism that affects ART use. A strength of this study is the use of in-depth interviews with a range of women; not just women who stayed on ART, but also women who refused, stopped and re-started in the context of Option B+. Even though there might be overlap between the findings here and other qualitative research, particular barriers become more salient for women initiating ART in the context of Option B+. In prior assessments, women were only initiated on ART after being immunologically compromised, an assessment which often took longer than a month. This gave women time to reflect and accept their condition and communicate with their partner. In the case of Option B+ women felt they needed this time to prepare. The study demonstrates that challenges with uptake and adherence to ART remain. More time and support for women in decision-making, consistent pre-ART counselling, and support with side-effects may contribute to improvements in the long-run. As ART becomes increasingly normalised, some of these barriers may disappear.

Africa
Malawi
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HIV and injecting ‘krokodile’

Krokodile Injectors in Ukraine: fueling the HIV Epidemic?

Booth RE, Davis JM, Brewster JT, Lisovska O, Dvoryak S. AIDS Behav. 2016 Feb;20(2):369-76. doi: 10.1007/s10461-015-1008-z.

This study was designed to assess the characteristics of krokodile injectors, a recent phenomenon in Ukraine, and HIV-related risk factors among people who inject drugs (PWID). In three Ukraine cities, Odessa, Donetsk and Nikolayev, 550 PWID were recruited between December 2012 and October 2013 using modified targeted sampling methods. The sample averaged 31 years of age and they had been injecting for over 12 years. Overall, 39% tested positive for HIV, including 45% of krokodile injectors. In the past 30 days, 25% reported injecting krokodile. Those who injected krokodile injected more frequently (p < 0.001) and they injected more often with others (p = 0.005). Despite knowing their HIV status to be positive, krokodile users did not reduce their injection frequency, indeed, they injected as much as 85% (p = 0.016) more frequently than those who did not know their HIV status or thought they were negative. This behavior was not seen in non-krokodile using PWID. Although only a small sample of knowledgeable HIV positive krokodile users was available (N = 12), this suggests that krokodile users may disregard their HIV status more so than non-krokodile users. In spite of widespread knowledge of its harmful physical consequences, a growing number of PWID are turning to injecting krokodile in Ukraine. Given the recency of krokodile use in the country, the associated higher frequency of injecting, a propensity to inject more often with others, and what could be a unique level of disregard of HIV among krokodile users, HIV incidence could increase in future years.

Abstract access

Editor’s notes: This is an important study among a highly vulnerable population of people who inject drugs where HIV prevalence has been consistently high over the last decade. This is one of the first empirical studies to examine the role of krokodile use on HIV risk acquisition. Krokodile is a home produced drug that has become more popular among people who inject drugs in Ukraine and the Russian Federation over the last five years. There is a long history of injection with home-produced opioids and amphetamines in these countries. The key component of krokodile is codeine, an opioid, but severe side effects have been associated with its injection including tissue damage, gangrene and organ failure. This study highlights some of the characteristics and HIV risk behaviours associated with krokodile injection to inform appropriate HIV prevention programming. Findings note that people who inject krokodile are more likely to inject with others. This reflects the home-produced nature of the drug that facilitates more group injecting as people congregate at places where it is produced to buy and inject. Programmes need to focus on strategies to avoid injecting with other people’s used injecting equipment, such as marking equipment, as can happen in group injecting scenarios. This programme would ensure there are sufficient numbers of clean needles/syringes in circulation. Worryingly, a higher prevalence of HIV was observed among people who inject krokodile, most likely associated with their older age and more frequent injecting. Targeted harm reduction information is urgently needed for krokodile users to prevent further HIV transmission and prevent soft tissue damage. There is already a large network of needle-syringe programmes and opioid substitution therapy available for people who inject drugs in Ukraine. However, access is often reduced since people who inject drugs are concerned about being arrested. Registration as a person who injects drugs causes problems with employment, families and police. Collaboration with the police is necessary to increase access to opioid substitution and needle and syringe programmes. Programmes are also required to reduce the stigma associated with injection in order to address the health needs of this population. 

Europe
Ukraine
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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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‘Cash, care and classroom’: social protection to reduce adolescents’ risk of HIV

Applying a family-level economic strengthening intervention to improve education and health-related outcomes of school-going AIDS-orphaned children: lessons from a randomized experiment in southern Uganda.

Ssewamala FM, Karimli L, Torsten N, Wang JS, Han CK, Ilic V, Nabunya P. Prev Sci. 2016 Jan;17(1):134-43. doi: 10.1007/s11121-015-0580-9.

Children comprise the largest proportion of the population in sub-Saharan Africa. Of these, millions are orphaned. Orphanhood increases the likelihood of growing up in poverty, dropping out of school, and becoming infected with HIV. Therefore, programs aimed at securing a healthy developmental trajectory for these orphaned children are desperately needed. We conducted a two-arm cluster-randomized controlled trial to evaluate the effectiveness of a family-level economic strengthening intervention with regard to school attendance, school grades, and self-esteem in AIDS-orphaned adolescents aged 12-16 years from 10 public rural primary schools in southern Uganda. Children were randomly assigned to receive usual care (counseling, school uniforms, school lunch, notebooks, and textbooks), "bolstered" with mentorship from a near-peer (control condition, n = 167), or to receive bolstered usual care plus a family-level economic strengthening intervention in the form of a matched Child Savings Account (Suubi-Maka treatment arm, n = 179). The two groups did not differ at baseline, but 24 months later, children in the Suubi-Maka treatment arm reported significantly better educational outcomes, lower levels of hopelessness, and higher levels of self-concept compared to participants in the control condition. Our study contributes to the ongoing debate on how to address the developmental impacts of the increasing numbers of orphaned and vulnerable children and adolescents in sub-Saharan Africa, especially those affected by HIV/AIDS. Our findings indicate that innovative family-level economic strengthening programs, over and above bolstered usual care that includes psychosocial interventions for young people, may have positive developmental impacts related to education, health, and psychosocial functioning.

Abstract access 

Editor’s notes: The HIV epidemic has left many sub-Saharan countries with an extraordinarily large youth population, many of whom lost one or both parents to HIV-associated mortality. As a result, younger children tend to have much less support to stay in education and older children often have increased responsibility to support the household. There is thus a need to provide orphaned children with both financial and psycho-social support to achieve their educational goals, and on a broader scale, to prepare the youth for the workforce. This study found that providing orphaned children with a package of school supplies and support services as well as financial services (opening a matched child savings account and workshops on microenterprise development) yielded better educational outcomes than the package without the additional financial services. However, how either group compares to non-orphaned children is unclear. Future research would benefit from a third comparison group, in which non-orphaned children’s educational outcomes are also compared.

The effect of the programme on both educational and mental outcomes among orphans is important. Educational outcomes may have been driven by improved self-confidence and motivation as a result of the savings account and microenterprise training. It is unclear whether these supplemental activities were simply a signal of the community support for the orphaned children, which in turn increased self-confidence, or if the children were directly influenced by their improved economic prospects. Further research to uncover the actual mechanism of the improved outcomes would be useful for future programme design. 

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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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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Why get tested for HIV in Russia?

Motivators and barriers to HIV testing among street-based female sex workers in St. Petersburg, Russia.

King EJ, Maman S, Dudina VI, Moracco KE, Bowling JM. Glob Public Health. 2015 Dec 28:1-16. [Epub ahead of print]

Female sex workers are particularly susceptible to HIV-infection in Russia. However, a dearth of information exists on their utilisation of HIV services. A mixed-methods, cross-sectional study was conducted to examine motivators and barriers to HIV testing among street-based sex workers in St. Petersburg, Russia. The health belief model was the theoretical framework for the study. Twenty-nine sex workers participated in in-depth interviews, and 139 sex workers completed interviewer-administered surveys between February and September 2009. Barriers to getting an HIV test were fear of learning the results, worrying that other people would think they were sick, and the distance needed to travel to obtain services. Motivators for getting tested were protecting others from infection, wanting to know one's status and getting treatment if diagnosed. Logistic regression analysis demonstrated that knowing people living with HIV [aOR = 6.75, 95% CI (1.11, 41.10)] and length of time since start of injection drug use [aOR = 0.30, 95% CI (0.09, 0.97)] were significantly associated with recently getting tested. These results are important to consider when developing public health interventions to help female sex workers in Russia learn their HIV status and get linked to care and treatment services if needed.

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Editor’s notes: This paper summarises findings from a mixed-method study among a sample of female sex workers in St Petersburg, Russian Federation, the majority of whom also inject drugs. This is an important study, allowing the voices of a highly marginalised group to be heard and highlighting barriers and facilitators to HIV testing. Improving access to testing among this population is particularly important given the increased risk of HIV infection that they face. They are susceptible to HIV infection through both sexual and injecting transmission routes. The paper raises some important points such as the widespread misunderstanding about the severity of HIV in the absence of symptoms. HIV was not perceived to be a major problem among the population; there were more immediate problems associated with drug use and sex work. The necessity to travel for testing was seen as a barrier to HIV testing. For a population with multiple and complex health needs this is an acute problem given the vertical structure of the Russian health system. There is a lack of integration across sexual health, drug dependency and HIV and other infectious disease treatment services necessary for this population.  Many other structural barriers were reported to testing including  fear of being registered as having HIV, fear of stigma from friends and health care workers, fear of the unknown associated with infection and disease progression and uncertainty about availability of HIV treatment.  Concerns about treatment availability are particularly relevant since people who inject drugs are often denied HIV treatment in the Russian Federation while they continue to use drugs. This point is important in understanding the context in which HIV testing is accessed. Further discussion on what real benefits knowing your status brings weighed up against the disadvantages of knowing, warrants further discussion in the paper. We know that there is limited and often interrupted HIV treatment available and few ancillary services (such as opioid substitution therapy) to support maintenance of treatment.  We also know that there is much stigma associated with being HIV positive. People living with HIV experience frequent problems with employment and concerns about having children taken into care. All these problems are compounded if you use drugs or sell sex. In this context, the benefits of knowing your status is questionable and is bound to influence uptake of testing.

Asia, Europe
Russian Federation
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