Articles tagged as "Stigma and social exclusion"

HIV and gay men and other men who have sex with men: an expanding and underfunded epidemic

Financing the response to HIV among gay men and other men who have sex with men: case studies from eight diverse countries.

Grosso A, Ryan O, Tram KH, Baral S. Glob Public Health. 2015 Dec;10(10):1172-84. doi: 10.1080/17441692.2015.1043314. Epub 2015 Jul 3.

Despite reductions in the number of new HIV infections globally, the HIV epidemic among men who have sex with men (MSM) is expanding. This study characterises financing of HIV programmes for MSM and the impact of criminalisation on levels of funding, using data from five countries that criminalise same-sex sexual practices (Ethiopia, Mozambique, Guyana, India and Nigeria) and three that do not (China, Ukraine and Vietnam). For each country, all publicly available documents from the Global Fund to Fight AIDS, Tuberculosis and Malaria for approved HIV/AIDS grants in Rounds 5-9 and Country Operational Plans detailing investments made through the President's Emergency Plan for AIDS Relief (PEPFAR) from US fiscal year (FY) 2007-2009 were examined. Eleven of 20 HIV proposals to the Global Fund contained programmes for MSM totalling approximately $40 million or 6% of proposed budgets. In six countries providing activity-level data on MSM programming, PEPFAR funding that served this population and others ranged from $23.3 million in FY2007 to $35.4 million in FY2009, representing 0.5-25.9% of overall, non-treatment funding over this period. Countries that criminalise same-sex sexual practices spend fewer resources on HIV programmes serving MSM. However, they also show consistent underfunding of programmes serving MSM regardless of context or geography.

 Abstract access

Editor’s notes: Despite encouraging indicators on the reduction of new HIV infections worldwide, the epidemic among gay men and other men who have sex with men continues to grow. This is due to both biological and structural factors. With many governments failing to take responsibility for this at-risk population, funding for gay men and other men who have sex with men-specific programmes often comes from international donors. This study looks at Global Fund and PEPFAR financing of programmes for gay men and other men who have sex with men, comparing funding availability and services offered both in settings where homosexuality is criminalised and settings where it is not.

The study finds that most proposed funding focuses on behaviour change communication, and less frequently on improving sexual health services, community outreach and education. Nations that criminalise homosexuality allocated about 2% of funding towards gay men and other men who have sex with men services, while countries without punitive measures allocated close to 7%. Importantly, both were felt to be inadequately small sums of money in relation to the size of the epidemic. Key stakeholder interviews from criminalising countries suggest that legal restrictions make it more difficult to provide services focused on gay men and other men who have sex with men. Although, little is known about the degree to which gay men and other men who have sex with men access services focused on the general population. The authors also note that countries that criminalise homosexuality may request funds for gay men and other men who have sex with men believing that donors will look favourably on budgets that include these activities. After receiving funds, these countries may re-programme activities, reducing or removing these focussed programmes.

There is comparatively little research done on HIV and gay men and other men who have sex with men in low- and middle-income countries, in particular in African settings. This article contributes to an expanding literature on the subject and raises questions about the role that international donors should play in ensuring an equitable access to services, particularly in the context of reprogramming. This highlights how real impact on the incidence of HIV among gay men and other men who have sex with men requires both demand generation and accountability in equal measure.

Africa, Asia, Europe, Latin America
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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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Weighing up the risks and benefits of trial participation: understanding non-adherence in a PrEP trial

Participants' explanations for non-adherence in the FEM-PrEP clinical trial.

Corneli A, Perry B, McKenna K, Agot K, Ahmed K, Taylor J, Malamatsho F, Odhiambo J, Skhosana J, Van Damme L. J Acquir Immune Defic Syndr. 2015 Nov 3. [Epub ahead of print]

Background: FEM-PrEP - a clinical trial of daily, oral emtricitabine/tenofovir disoproxil fumarate for HIV prevention among women in sub-Saharan Africa - did not show a reduction in HIV acquisition because of low adherence to the study pill. We conducted a follow-up study to identify reasons for non-adherence.

Methods: Qualitative, semi-structured interviews (n=88) and quantitative, audio computer-assisted self-interviews (n=224) were conducted with former FEM-PrEP participants in Bondo, Kenya, and Pretoria, South Africa. Thematic analysis was used to analyze the qualitative data, and descriptive statistics were used to describe ACASI responses. Data are presented within the five categories of Ickovics' and Meisler's conceptual framework on adherence: 1) the individual, 2) trial characteristics and study pill regimen, 3) patient-provider relationship, 4) clinical setting, and 5) the disease.

Results: Participants' explanations for non-adherence were primarily situated within three of the framework's five categories: 1) the individual, 2) trial characteristics and study pill regimen, and 3) the disease. Concerns about the investigational nature of the drug being tested and side effects were the prominent reasons reported for non-adherence. Participants also described being discouraged from taking the study pill by members of the community, their sexual partners, and other participants, primarily because of these same concerns. Limited acceptability of the pill's attributes influenced non-adherence for some participants as did concerns about HIV-related stigma. Additionally, many participants reported that others continued in FEM-PrEP while not taking the study pill because of the trial's ancillary benefits and visit reimbursement - factors related to the clinical setting. Negative patient-provider relationships were infrequently reported as a factor that influenced non-adherence.

Conclusion: Despite substantial study staff engagement with participants and communities, concerns about the study pill and discouragement from others appeared to have influenced non-adherence considerably. Alternative study designs or procedures and enhanced community engagement paradigms may be needed in future studies.

Abstract access 

Editor’s notes: The authors of this important paper on a PrEP trial, end with a note of caution. They note that when interpreting the findings we should remember that the women in this study were taking a ‘study product’. The women were not taking a product of proven efficacy. Therefore, as the authors state, it would be wrong to assume that ‘African women cannot and will not be adherent if provided with PrEP outside of a clinical trial setting’. If they had been told that the product was efficacious, they may have behaved differently. This is important because a key message of the paper is that trial participants managed their participation so they felt comfortable in the trial. Many wanted to ensure they received benefits from their participation, including good health care, but they also wanted to manage risk. Risk associated with fears about the trial drug and risk from the disapproval of sexual partners about their participation. It is also very clear in these findings that the participants could manage the expectations of the trial team, by telling them what they wanted to hear during the trial. This suggests the limited value of ‘adherence questionnaires’ in some settings. The authors provide a powerful illustration of the value of mixed methods in trials of this sort. Drug concentration data told the researchers that many women were not adhering to the drug. Qualitative semi-structured interviews using this drug concentration data with the individual women helped the team to understand why. The authors also discuss the influence of community and family members in undermining participant faith in the trial. They explain the lengths that the trial team went to, to inform community members about the trial. Considerable time was given to sharing information. Doubts remained; concerns that were enough to discourage participation. This too is an important finding underlining the value of investing in community engagement in research. But it also highlights the need to find ways to enhance not just engagement, but also understanding and trust. 

Africa
Kenya, South Africa
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Awareness of HIV status and risk among key populations in India

HIV care continuum among men who have sex with men and people who inject drugs in India: barriers to successful engagement.

Mehta SH, Lucas GM, Solomon S, Srikrishnan AS, McFall AM, Dhingra N, Nandagopal P, Kumar MS, Celentano DD, Solomon SS. Clin Infect Dis. 2015 Aug 6. pii: civ669. [Epub ahead of print]

Background: We characterize the HIV care continuum for men who have sex with men (MSM) and people who inject drugs (PWID) across India.

Methods: We recruited 12 022 MSM and 14 481 PWID across 26 Indian cities using respondent-driven sampling (9/2012-12/2013). Participants were ≥18 years and either 1) self-identified as male and reported sex with a man in the prior year (MSM); or 2) reported injection drug use in the prior 2 years (PWID). Correlates of awareness of HIV positive status were characterized using multi-level logistic regression.

Results: 1146 MSM were HIV-infected of whom a median 30% were aware of their HIV positive status, 23% were linked to care, 22% were retained pre-ART, 16% initiated ART, 16% were currently on ART, and 10% had suppressed VL. There was site variability (awareness range: 0-90%; suppressed VL range: 0-58%). 2906 PWID were HIV-infected of whom a median 41% were aware, 36% linked to care, 31% were retained pre-ART, 20% initiated ART, 18% were currently on ART, and 15% had suppressed VL. Similar site variability was observed (awareness range: 2-93%; suppressed VL range: 0-47%). Factors significantly associated with awareness were region, older age, being married (MSM) or female (PWID), other service utilization (PWID), more lifetime sexual partners (MSM) and needle sharing (PWID). Ongoing injection drug use (PWID) and alcohol (MSM) were associated with lower awareness.

Conclusions: In this large sample, the major barrier to HIV care engagement was awareness of HIV positive status. Efforts should focus on linking HIV testing to other essential services.

Abstract access 

Editor’s notes: The UNAIDS target of 90-90-90 (90% of HIV positive individuals knowing their status, 90% of people being on ART and 90% of people on ART being virally suppressed) applies to all people living with HIV, including people in key populations who can be hard to reach in some settings. In India, declines in HIV prevalence have been seen among women attending antenatal clinics, but not in the key populations of gay men and other men who have sex with men and people who inject drugs. In this large, community-based, study of gay men and other men who have sex with men and people who inject drugs across India, the majority of people living with HIV (70% of gay men and other men who have sex with men and 59% of people who inject drugs) were unaware of their HIV status. Of people who were aware of their status, the proportions receiving sustained ART were relatively low (68% of gay men and other men who have sex with men and 52% of people who inject drugs). Notably, among people on ART, levels of viral suppression were high and comparable to that in high-income settings. The study highlights awareness of HIV status as the primary barrier to HIV care in these populations, and the importance of integrating HIV testing across healthcare services for vulnerable populations, using same-day rapid tests to maximise linkage-to-care. However, to have a real impact on outcomes across the HIV care continuum, additional strategies will be necessary. These are needed together with large-scale public policy changes to modify the broader social environment – such as decriminalisation of same-sex behaviour.

Asia
India
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Patient support networks may improve long-term engagement in HIV care

Implementation and operational research: pulling the network together: quasiexperimental trial of a patient-defined support network intervention for promoting engagement in HIV care and medication adherence on Mfangano Island, Kenya.

Hickey MD, Salmen CR, Omollo D, Mattah B, Fiorella KJ, Geng EH, Bacchetti P, Blat C, Ouma GB, Zoughbie D, Tessler RA, Salmen MR, Campbell H, Gandhi M, Shade S, Njoroge B, Bukusi EA, Cohen CR. J Acquir Immune Defic Syndr. 2015 Aug 1;69(4):e127-34. doi: 10.1097/QAI.0000000000000664.

Background: Despite progress in the global scale-up of antiretroviral therapy, sustained engagement in HIV care remains challenging. Social capital is an important factor for sustained engagement, but interventions designed to harness this powerful social force are uncommon.

Methods: We conducted a quasiexperimental study evaluating the impact of the Microclinic Social Network intervention on engagement in HIV care and medication adherence on Mfangano Island, Kenya. The intervention was introduced into 1 of 4 similar communities served by this clinic; comparisons were made between communities using an intention-to-treat analysis. Microclinics, composed of patient-defined support networks, participated in 10 biweekly discussion sessions covering topics ranging from HIV biology to group support and group HIV status disclosure. Nevirapine concentrations in hair were measured before and after study.

Results: One hundred thirteen (74%) intervention community participants joined a microclinic group, 86% of whom participated in group HIV status disclosure. Over 22-month follow-up, intervention community participants experienced one-half the rate of ≥ 90-day clinic absence as those in control communities (adjusted hazard ratio: 0.48; 95% confidence interval: 0.25 to 0.92). Nevirapine hair levels declined in both study arms; in adjusted linear regression analysis, the decline was 6.7 ng/mg less severe in the intervention arm than control arm (95% confidence interval: -2.7 to 16.1).

Conclusions: The microclinic intervention is a promising and feasible community-based strategy to improve long-term engagement in HIV care and possibly medication adherence. Reducing treatment interruptions using a social network approach has important implications for individual patient virologic suppression, morbidity, and mortality and for broader community empowerment and engagement in healthcare.

Abstract access 

Editor’s notes: To maximise the impact of ART, people living with HIV should be diagnosed early, enrolled and retained in pre-ART care, initiated on ART and retained in ART care. Long-term adherence to achieve and maintain viral load suppression is the last step in the continuum of HIV care. Engagement along the complete treatment cascade will determine the long-term success of the global response to HIV.

This article reports on the results of a quasi-experimental study that assessed whether a combined stigma reduction and social network empowerment programme resulted in improved HIV treatment outcomes. The programme consisted of an adaptation of a social network-based activity known as ‘microclinics’. ‘Microclinics’ are informal social networks empowered to support chronic disease management and prevention. ‘Microclinic’ groups consisted of five to ten close family, friends or other members of the patient’s social support system, irrespective of the member’s HIV status. ‘Microclinics’ were assigned a Community Health Worker coordinator and facilitator and were guided through a series of ten discussion sessions over a period of five months. During these sessions they received health education messages to promote knowledge of HIV prevention and treatment, and group support was promoted through discussion of confidentiality, HIV status disclosure, and encouragement of group support for adherence and clinic attendance. The programme was introduced into one of four similar communities served by the main study clinic, and comparisons were made between communities. The outcomes were engagement in HIV care and medication adherence. 

Three-quarters of participants in the programme community joined a ‘microclinic’. Participants in the programme community spent a larger proportion of time adherent to clinic schedules. On average, during a year of follow-up, compared to people in the control group, people in the ‘microclinics’ group returned to care three weeks sooner after a missed visit. Work by Ware et al. describes a pathway from missing a clinic visit to disengaging from care. The pathway includes as intermediate steps, developing a reluctance to return, and subsequent feelings of decreased connectedness to care. The authors of this study hypothesise that ‘microclinic’ participation prevented the development of ‘reluctance to return’ after a missed visit.

The authors conclude that there is empiric support for ‘microclinics’ as an effective model for chronic disease management. But, given the quasi-experimental design, other factors may have contributed to improved outcomes. Data from longer term follow up would be useful to determine the durability of the programme effect, since study participants were only followed up for 22 months. 

Africa
Kenya
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Global programmes and local discrimination: the inadequate support of women living with HIV in West Papua and its impact on PMTCT

(Not) getting political: indigenous women and preventing mother-to-child transmission of HIV in West Papua.

Munro J, McIntyre L. Cult Health Sex. 2015 Aug 25:1-16. [Epub ahead of print]

This paper builds on critiques that call for a more nuanced and contextualised understanding of conditions that affect HIV prevention by looking at West Papuan women's experiences of prevention of mother-to-child transmission services. Drawing on qualitative, ethnographic research with indigenous women and health workers, the paper demonstrates that women experience poor-quality HIV education and counselling, and that indigenous practices and concerns are largely not addressed by HIV services. We attribute this to a combination of national anti-indigenous and anti-separatist political concerns with donor-led interventions that result in limited localisation and reduced effectiveness of HIV prevention measures. In West Papua, services are needed that enhance cooperation and shared commitment, and that acknowledge and work to overcome existing inequalities, ethnic tensions and discrimination in the health system. Beyond Indonesia, donor-led HIV programmes and interventions need to balance avoidance of politically sensitive issues with complicity in perpetuating health inequalities. Translating global health interventions and donor priorities into locally compelling HIV prevention activities involves more than navigating local cultural and religious beliefs. Programme development and implementation strategies that entail confronting structural questions as well as social hierarchies, cleavages and silences are needed to render more effective services; strategies that are inherently political.

Abstract access 

Editor’s notes: West Papua is witnessing one of the fastest growing HIV epidemics in the world, especially among its indigenous populations (prevalence is 2.9%). Translation of HIV prevention programmes to the local situation is complicated by unequal, discriminatory and racialised relationships between the Indonesian government and indigenous Papuans. This is made worse by the exclusion of indigenous Papuans from health services management and governance. Tensions between Papuan HIV NGO staff and Indonesian healthcare workers create obstacles to delivery of health promotion and HIV testing. International HIV agency funders and representatives ignore these tensions for political reasons.

Indigenous people are stigmatised as ‘hypersexual’ and ‘wild’ which causes poor service design and delivery of prevention of mother-to-child transmission. Because of racial stereotypes, Papuan women receive inadequate education and support in the healthcare system. Many women do not fully understand prevention of mother-to-child transmission, antiretroviral therapy, infant feeding choices, and delivery choices. Women are uncomfortable with healthcare workers and do not trust their advice, which is inadequate and does not consider peoples’ views. Women often drop out of HIV care after testing. Women were very isolated, with their partners often working far away. Women disclose their HIV status to very few people even with their families and usually do not know other positive mothers. International donor agencies need to engage with existing local political tensions that result in poor quality treatment of service users. HIV prevention programmes can exacerbate local inequalities if these are not recognised in HIV policy and service provision. 

Asia
Indonesia
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Risks and experiences of transgender women in Lebanon

Forms of safety and their impact on health: an exploration of HIV/AIDS-related risk and resilience among trans women in Lebanon.

Kaplan RL, Wagner GJ, Nehme S, Aunon F, Khouri D, Mokhbat J. Health Care Women Int. 2015 Aug;36(8):917-35. doi: 10.1080/07399332.2014.896012. Epub 2014 Apr 9.

Using minority stress theory, the authors investigated risk behaviors of transgender women (trans women) in Lebanon. Using semistructured interviews, the authors explored six areas: relationships with family and friends; openness about gender and sexuality; experiences with stigma; sexual behavior; attitudes and behaviors regarding HIV testing; and perceived HIV-related norms among transgender peers. Participants voiced the importance of different forms of safety: social/emotional, physical, sexual, and financial. Strategies for obtaining safety were negotiated differently depending on social, behavioral, and structural factors in the environment. In this article, we provide study findings from the perspectives of trans women, their exposure to stigma, and the necessary navigation of environments characterized by transphobia

Abstract access                     

Editor’s notes: Transgender women have a high risk of HIV acquisition / transmission, due to experiences of stigma, discrimination and transphobia. However there is a dearth of studies on transgender women from North Africa or the Middle East.

Interviews with ten trans-women from Beirut were included in this qualitative study. The study findings highlight the extreme vulnerability of transgender women to stigma, discrimination, violence, mental ill-health, financial insecurity and HIV and STI risk. Social support and emotional security from family, friends, and the transgender community was frequently lacking. Mental ill-health (9/10) and suicide ideation / attempts was high (5/10). Stigma and discrimination by peers and teachers at school, and at the work-place were common. Many also reported verbal, physical and sexual abuse and violence in public spaces. Many participants were selling anal sex to reduce financial insecurity. Money was a key motivator for condom non-use. 

Programmes with transgender women should be multi-component to reflect the complexity of their needs. They should include HIV prevention, advocacy of laws to prevent discrimination, employment opportunities to enable economic independence, and treatment and support for mental ill-health.

Asia
Lebanon
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Regressive laws on same sex relationships increases stigma and reduces health service use

The immediate effect of the Same-Sex Marriage Prohibition Act on stigma, discrimination, and engagement on HIV prevention and treatment services in men who have sex with men in Nigeria: analysis of prospective data from the TRUST cohort.

Schwartz SR, Nowak RG, Orazulike I, Keshinro B, Ake J, Kennedy S, Njoku O, Blattner WA, Charurat ME, Baral SD, TRUST Study Group. Lancet HIV. 2015 Jul 1;2(7):e299-e306.

Background: In January, 2014, the Same-Sex Marriage Prohibition Act was signed into law in Nigeria, further criminalising same-sex sexual relationships. We aimed to assess the immediate effect of this prohibition act on stigma, discrimination, and engagement in HIV prevention and treatment services in men who have sex with men (MSM) in Nigeria.

Methods: The TRUST cohort study uses respondent-driven sampling to assess the feasibility and effectiveness of engagement of MSM in HIV prevention and treatment services at a clinical site located with a community-based organisation trusted by the MSM community. TRUST is a prospective implementation research cohort of MSM (≥16 years) in Abuja, Nigeria. We compared HIV clinical outcomes and stigma, including fear and avoidance of health care, across baseline and quarterly visits before and after implementation of the Same-Sex Marriage Prohibition Act. Outcomes assessed were measures of stigma and discrimination, loss to follow-up, antiretroviral therapy status, and viral load. We compared outcomes before and after the legislation with chi2 statistics, and estimated incident stigma-related events and loss to follow-up with Poisson regression.

Findings: Between March 19, 2013, and Aug 7, 2014, 707 MSM participated in baseline study procedures, contributing to 756 before legislation (prelaw) and 420 after legislation (postlaw) visits. Reported history of fear of seeking health care was significantly higher in postlaw visits than in prelaw visits (n=161 [38%] vs n=187 [25%]; p<0.0001), as was avoidance of health care (n=118 [28%] vs n=151 [20%]; p=0.001). In incidence analyses, of 192 MSM with follow-up data and no history of an event at baseline, reported fear of seeking health care was higher in the postlaw than the prelaw period (n=144; incidence rate ratio 2.57, 95% CI 1.29-5.10; p=0.007); loss to follow-up and incident healthcare avoidance were similar across periods. Of the 161 (89%) of 181 HIV-infected MSM with HIV viral loads available, those who had disclosed sexual behaviour with a health-care provider were more often virally suppressed at baseline than those with no previous disclosure (18 [29%] of 62 vs 13 [13%] of 99 men; p=0.013).

Interpretation: These analyses represent individual-level, quantitative, real-time prospective data for the health-related effects resulting from the enactment of legislation further criminalising same-sex practices. The negative effects of HIV treatment and care in MSM reinforce the unintended consequences of such legislation on global goals of HIV eradication. Strategies to reach MSM less likely to engage in HIV testing and care in highly stigmatised environments are needed to reduce time to HIV diagnosis and treatment.

Abstract access 

Editor’s notes: Despite the recent implementation of progressive laws on same-sex relationships and marriage in several settings, other countries – including Nigeria – have moved to criminalise same sex practises. As well as broader human rights concerns, there is the risk that policies that criminalise same-sex practices, or the community groups addressing the health-related needs of these populations, might restrict the coverage of HIV prevention, treatment and care programmes. However, despite these concerns, there is extremely limited quantitative evidence on the impact of such policies. In Nigeria, the Same-Sex Marriage Prohibition Act was passed in 2011, coming into law in 2014. Before this legislation, consensual sex between male same-sex couples was already prohibited. The new law further criminalised same sex practices, including prohibiting participation in organisations and service provision. This study opportunistically analysed data from an on-going prospective cohort study of gay men and other men who have sex with men in Abuja, which had started prior to the law’s implementation, and continued after its introduction. The study assessed the degree to which this legislation impacted on gay men and other men who have sex with men’s fear and health service use. Unsurprisingly, perhaps, the study illustrates that the law did impact negatively on gay men and other men who have sex with men – significantly increasing their fear of and avoidance of health services, as well as increasing their levels of harassment and experience of blackmail. Prior to the new legislation, levels were already high, with the new law seeming to exacerbate existing barriers and stigma. The findings are important, illustrating how regressive laws can increase the stigmatisation of already marginalised groups, and undermine the gay men and other men who have sex with men’s access to health associated services. Supportive policy environments, along with HIV programmes for marginalised populations, form an essential part of an effective HIV response.

Africa
Nigeria
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Expansions in HIV treatment believed to reduce HIV stigma

HIV treatment scale-up and HIV-related stigma in sub-Saharan Africa: a longitudinal cross-country analysis.

Chan BT, Tsai AC, Siedner MJ. Am J Public Health. 2015 Jun 11:e1-e7. [Epub ahead of print] doi:10.2105/AJPH.2015.302716

Objectives: We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa.

Methods: We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable.

Results: Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = -0.226; P = .007; 95% confidence interval [CI] = -0.383, -0.070) and men (b = -0.281; P = .009; 95% CI = -0.480, -0.082) in the general population reporting HIV-related stigma.

Conclusions: An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population. .

Abstract access 

Editor’s notes: Focused on sub-Saharan Africa, this study suggests that a benefit of the scale-up of antiretroviral therapy (ART) may have been a reduction in HIV-associated stigma. The authors combine data on HIV-associated stigma from the Demographic and Health Surveys and AIDS Indicator Surveys with data on ART coverage from UNAIDS. The results are presented for each of 18 countries and the authors suggest that increases in ART coverage are correlated with decreasing stigma, especially among countries with high HIV prevalence. The authors hypothesise that by allowing a person with HIV to experience a healthier life, ART reduces the stigma of HIV’s association with moral deviance. The authors also attribute knowledge to decreases in stigma.

While addressing an interesting and important question, the paper has some limitations. We suggest that participant responses to questions about whether they would be willing to care for someone “sick with AIDS”, and whether they would want a family member to keep an AIDS diagnosis “secret” cannot safely be interpreted as reflecting stigmatising attitudes or anticipated stigma. It would have been interesting to know if the methods used in the analysis could assess the role of ART relative to other factors in being associated with any changes over time in HIV-associated stigma.

Africa
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Men who have sex with men in sub-Saharan Africa: a review of the evidence

Emerging themes for sensitivity training modules of African healthcare workers attending to men who have sex with men: a systematic review.

Dijkstra M, van der Elst EM, Micheni M, Gichuru E, Musyoki H, Duby Z, Lange JM, Graham SM, Sanders EJ. Int Health. 2015 May;7(3):151-162. Epub 2015 Jan 16.

Sensitivity training of front-line African health care workers (HCWs) attending to men who have sex with men (MSM) is actively promoted through national HIV prevention programming in Kenya. Over 970 Kenyan-based HCWs have completed an eight-modular online training free of charge (http://www.marps-africa.org) since its creation in 2011. Before updating these modules, we performed a systematic review of published literature of MSM studies conducted in sub-Saharan Africa (sSA) in the period 2011-2014, to investigate if recent studies provided: important new knowledge currently not addressed in existing online modules; contested information of existing module topics; or added depth to topics covered already. We used learning objectives of the eight existing modules to categorise data from the literature. If data could not be categorised, new modules were suggested. Our review identified 142 MSM studies with data from sSA, including 34 studies requiring module updates, one study contesting current content, and 107 studies reinforcing existing module content. ART adherence and community engagement were identified as new modules. Recent MSM studies conducted in sSA provided new knowledge, contested existing information, and identified new areas of MSM service needs currently unaddressed in the online training.

Abstract  Full-text [free] access

Editor’s notes: Same sex practices remain criminalised in sub-Saharan Africa. Gay men and other men who have sex with men face stigma, discrimination, harassment and arrest. Health care workers frequently have no training on issues affecting gay men and other men who have sex with men and are ill-prepared to work sensitively with them. Together these can deter these men from accessing health care and HIV/STI services, increasing their risk of HIV and other poor health outcomes.

This study conducted a systematic review of gay men and other men who have sex with men in sub-Saharan Africa. The findings were used to update an on-line training programme for health care workers in Kenya. This previously comprised modules on i) men who have sex with men and HIV in Africa ii) homophobia: stigma and its effects; iii) sexual identity, coming out and disclosure; iv) anal sex and common sexual practices; v) HIV and STIs; vi) condom and lubricant use; vii) mental health: anxiety, depression and substance use; and viii) risk-reduction counselling. The review updated the training programme with new evidence and two new modules were introduced: ix) ART adherence; and x) community engagement.

Health care workers play a crucial role in reducing stigma and discrimination facing gay men and other men who have sex with men. This systematic review provided a valuable step in updating an important, accessible training programme. Reducing homoprejudice and ensuring health care workers have accurate and up-to-date knowledge are key to improving service uptake by gay men and other men who have sex with men.

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