Articles tagged as "Stigma and social exclusion"

Community-based rapid testing boosts case finding among MSM in China

Case finding advantage of HIV rapid tests in community settings: men who have sex with men in 12 programme areas in China, 2011.

Zhang D, Qi J, Fu X, Meng S, Li C, Sun J. Int J STD AIDS. 2015 May;26(6):402-13. doi: 10.1177/0956462414542986. Epub 2014 Jul 15.

We sought to describe the advantage of rapid tests over ELISA tests in community-based screening for HIV among men who have sex with men (MSM) in urban areas of China. Data of 31 406 screening tests conducted over six months in 2011 among MSM across 12 areas were analyzed to compare the differences between those receiving rapid testing and ELISA. Rapid tests accounted for 45.8% of these screening tests. The rate of being screened positive was 7.2% among rapid tests and 5.3% for ELISA tests (X(2)= 49.161, p < 0.001). This advantage of rapid test in HIV case finding persisted even when socio-demographic, behavioural, screening recruitment channel and city were controlled for in logistic regression (exp[beta] = 1.42, p < 0.001, 95% CI = 1.27,1.59). MSM who received rapid tests, compared with those tested by ELISA, were less likely to use condoms during last anal sex (50.8% vs. 72.3%, X(2)= 1706.146, p < 0.001), more likely to have multiple sex partners (55.7% vs. 49.5%, X(2)= 238.188, p < 0.001) and less likely to have previously undergone HIV testing (38.8% vs. 54.7%, X(2)= 798.476, p < 0.001). These results demonstrate the robustness of the advantage of rapid tests over traditional ELISA tests in screening for MSM with HIV infection in cooperation with community-based organizations in urban settings in China.

Abstract access

Editor’s notes: The prevalence of HIV among gay men and other men who have sex with men in China has increased from 1% to 5% between 2006 and 2011. The increase in prevalence has motivated the development of a new HIV testing strategy to reach this key population. The China-Gates HIV Programme facilitated partnerships between local government health departments with community-based organizations (CBO) to reach and offer rapid HIV screening tests to gay men and other men who have sex with men in 14 cities and one province. Between July and December 2011, 17 015 men were tested through established HIV testing sites (run solely by the health departments, which used enzyme-linked immunosorbent assay [ELISA] testing) and another 14 391 men were tested at sites which were established, promoted, and run by the government-CBO partnerships. These sites used rapid HIV tests, and referred to the health department for confirmatory testing. After controlling for sociodemographic characteristics, transmission risk factors and geographic location, the odds of testing positive for HIV was 42% higher for men who were screened at partnership sites. This partnership demonstrates an innovative, culturally appropriate and scale-able model. For key populations, partnerships of this nature can lead to earlier treatment initiation and a reduction in secondary transmission.

Asia
China
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How the type of chronic illness in a household affects a child’s risk of abuse: findings from South Africa

Household illness, poverty and physical and emotional child abuse victimisation: findings from South Africa's first prospective cohort study.

Meinck F, Cluver LD, Boyes ME. BMC Public Health. 2015 May 1;15(1):444. doi: 10.1186/s12889-015-1792-4.

Background: Physical and emotional abuse of children is a large scale problem in South Africa, with severe negative outcomes for survivors. Although chronic household illness has shown to be a predictor for physical and emotional abuse, no research has thus far investigated the different pathways from household chronic illness to child abuse victimisation in South Africa.

Methods: Confidential self-report questionnaires using internationally utilised measures were completed by children aged 10-17 (n = 3515, 56.7% female) using door-to-door sampling in randomly selected areas in rural and urban locations of South Africa. Follow-up surveys were conducted a year later (96.7% retention rate). Using multiple mediation analyses, this study investigated direct and indirect effects of chronic household illness (AIDS or other illness) on frequent (monthly) physical and emotional abuse victimisation with poverty and extent of the ill person's disability as hypothesised mediators.

Results: For children in AIDS-ill families, a positive direct effect on physical abuse was obtained. In addition, positive indirect effects through poverty and disability were established. For boys, a positive direct and indirect effect of AIDS-illness on emotional abuse through poverty were detected. For girls, a positive indirect effect through poverty was observed. For children in households with other chronic illness, a negative indirect effect on physical abuse was obtained. In addition, a negative indirect effect through poverty and positive indirect effect through disability was established. For boys, positive and negative indirect effects through poverty and disability were found respectively. For girls, a negative indirect effect through poverty was observed.

Conclusions: These results indicate that children in families affected by AIDS-illness are at higher risk of child abuse victimisation, and this risk is mediated by higher levels of poverty and disability. Children affected by other chronic illness are at lower risk for abuse victimisation unless they are subject to higher levels of household disability. Interventions aiming to reduce poverty and increase family support may help prevent child abuse in families experiencing illness in South Africa.

Abstract  Full-text [free] access

Editor’s notes: Research has illustrated that children in an HIV- affected household in sub-Saharan Africa are at an increased risk of child maltreatment. This is the first longitudinal study to examine pathways from household chronic illness to child abuse in the developing world through multiple mediation analysis. Using confidential self-report questionnaires the study collected data from 3515 children (aged 10 to 17 years) in South Africa.

What is striking in their findings is the difference that they found in the relationship between risk of child abuse and the type of illness affecting the household, mediated by poverty and disability. They noted higher levels of physical and emotional abuse among HIV-affected households compared to households without HIV. However, they also found that households affected by other chronic illness had lower abuse prevalence rates. Given that diabetes and high blood pressure are more likely to affect older age people, the authors hypothesise that the ill member of the household would likely have access to a state pension and thus benefit from some protection from the risk of poverty. The exception to this hypothesis were households within this group who had high levels of disability.

This study provides a valuable contribution because previous research has primarily focused on AIDS or cancer-affected households. These households are likely to need to manage higher levels of associated stigma, a shorter perceived life expectancy and more complex treatment options. As such previous research may have presented a more extreme relationship between illness status of household and a child’s risk of abuse. The findings highlight the significance for activities and programming in identifying two groups of households which are at heightened risk for child abuse: HIV affected households; and households affected by other chronic conditions. 

Africa
South Africa
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People living with HIV at higher risk of developing disabilities in sub-Saharan Africa

The relationship between HIV and prevalence of disabilities in sub-Saharan Africa: systematic review.

Banks LM, Zuurmond M, Ferrand R, Kuper H. Trop Med Int Health. 2015 Apr;20(4):411-29. doi: 10.1111/tmi.12449. Epub 2015 Jan 14.

Objective: To systematically review evidence on the prevalence and risk of disabilities among children and adults living with HIV in sub-Saharan Africa.

Methods: Articles were identified from 1980 to June 2013 through searching seven electronic databases. Epidemiological studies conducted in sub-Saharan Africa that explored the association between HIV status and general disability or specific impairments, with or without an HIV-uninfected comparison group, were eligible for inclusion.

Results: Of 12 867 records initially identified, 61 papers were deemed eligible for inclusion. The prevalence of disability was high across age groups, impairment types and study locations. Furthermore, 73% of studies using an HIV- comparator found significantly lower levels of functioning in people living with HIV (PLHIV). By disability type, the results were as follows: (i) for studies measuring physical impairments (n = 14), median prevalence of limitations in mobility and motor function among PLHIV was 25.0% (95% CI: 21.8-28.2%). Five of eight comparator studies found significantly reduced functioning among PLHIV; for arthritis, two of three studies which used an HIV- comparison group found significantly increased prevalence among PLHIV; (ii) for sensory impairment studies (n = 17), median prevalence of visual impairment was 11.2% (95%CI: 9.5-13.1%) and hearing impairment was 24.1% (95%CI: 19.2-29.0%) in PLHIV. Significantly increased prevalence among PLHIV was found in one of four (vision) and three of three studies (hearing) with comparators; (iii) for cognitive impairment in adults (n = 30), median prevalence for dementia was 25.3% (95% CI: 22.0-28.6%) and 40.9% (95% CI: 37.7-44.1%) for general cognitive impairment. Across all types of cognitive impairment, twelve of fourteen studies found a significant detrimental effect of HIV infection; (iv) for developmental delay in children with HIV (n = 20), median prevalence of motor delay was 67.7% (95% CI: 62.2-73.2%). All nine studies that included a comparator found a significant difference between PLHIV and controls; for cognitive development and global delay, a significant detrimental effect of HIV was found in five of six and one of two studies, respectively. In the nine cohort studies comparing vertically infected and uninfected children, eight showed a significant gap in development over time in children with HIV. Finally, fifteen of thirty-one (48%) studies found a statistically significant dose-response relationship between indicators of disease progression (CD4 or WHO stage) and disability.

Conclusions: HIV is widespread in sub-Saharan Africa and the evidence suggests that it is linked to disabilities, affecting a range of body structures and functions. More research is needed to better understand the implications of HIV-related disability for individuals, their families as well as those working in the fields of disability and HIV so that appropriate interventions can be developed.

Abstract  Full-text [free] access

Editor’s notes: As ART is scaled-up, and people living with HIV live longer, an increasing number of people will face challenges of HIV-associated disability. Disability may be partly a direct effect of living with HIV, but may also be an indirect effect, for example due to side effects of treatment. There has been relatively little research on this topic, particularly in low and middle-income countries and this is the first systematic review of the prevalence of disability among people living with HIV in sub-Saharan Africa. The review found a high prevalence of all categories of disability. The majority of studies had an HIV-negative comparison group among whom levels of disability were lower than among people living with HIV. Developmental delay was the impairment most strongly linked to HIV, with prevalence as high as 78% in children living with HIV. To minimize the chance that the observed association was due to reverse causality, the review excluded studies which clearly focused on disability as a risk factor for HIV, although it is likely that some studies still included individuals in whom disability preceded HIV infection. There was also relatively little data on ART status and duration in many studies, which may impact on the association of HIV and disability.  Despite these limitations, this study highlights the need to focus on prevention and management of HIV-associated disability in sub-Saharan Africa and development of effective, low-cost evidence-informed activities.

Africa
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Good dads stay healthy!

" . . . I should maintain a healthy life now and not just live as I please . . . ": men's health and fatherhood in rural South Africa.

Hosegood V, Richter L, Clarke L. Am J Mens Health. 2015 May 25. pii: 1557988315586440. [Epub ahead of print]

This study examines the social context of men's health and health behaviors in rural KwaZulu-Natal, South Africa, particularly in relationship to fathering and fatherhood. Individual interviews and focus groups were conducted with 51 Zulu-speaking men. Three themes related to men's health emerged from the analysis of transcripts: (a) the interweaving of health status and health behaviors in descriptions of "good" and "bad" fathers, (b) the dominance of positive accounts of health and health status in men's own accounts, and (c) fathers' narratives of transformations and positive reinforcement in health behaviors. The study reveals the pervasiveness of an ideal of healthy fathers, one in which the health of men has practical and symbolic importance not only for men themselves but also for others in the family and community. The study also suggests that men hold in esteem fathers who manage to be involved with their biological children who are not coresident or who are playing a fathering role for nonbiological children (social fathers). In South Africa, men's health interventions have predominantly focused on issues related to HIV and sexual health. The new insights obtained from the perspective of men indicate that there is likely to be a positive response to health interventions that incorporate acknowledgment of, and support for, men's aspirations and lived experiences of social and biological fatherhood. Furthermore, the findings indicate the value of data on men's involvement in families for men's health research in sub-Saharan Africa.

Abstract access 

Editor’s notes: As the authors of this paper note, a lot of research has looked at men’s sexual and health-associated behaviour as risk factors for HIV infection of their partners and themselves. Far less attention has been paid to men’s family situation and how this, and how they view their family role, shapes their health behaviours. This paper begins to fill that gap. Using data from in-depth interviews and group discussions with 51 men in KwaZulu-Natal, South Africa, the authors describe how men view themselves as ‘fathers’ and how this affects what they do. Each of the men set out what this role means for how they behave and believe other fathers should behave. While the authors note that the sample would have been biased towards men happy to talk about being a father, the results are quite striking. The men frequently described the positive things they did for their children and wanted to do for their families. They claimed their own health behaviours to be exemplary. The men compared ‘good’ fathers with ‘bad’ fathers’, men who drank and were sexually promiscuous. All the respondents were ‘good’ fathers. Not one of the men disclosed their HIV-status during the interviews. The authors note that the men were much freer discussing diet, weight, smoking and alcohol than HIV. Given HIV-associated stigma and the negative stereotypes of promiscuous men spreading infection, it is hardly surprising that men constructed a positive identity through their narratives and distanced themselves from personal HIV-associated discussion. Tailored health messages which reinforce the behaviour of ‘good fathers’ are likely to have a greater impact on these men’s sexual behaviour than messages that aim to scare.

Africa
South Africa
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Missed opportunities for early infant diagnosis in South Africa

Missed opportunities for early infant HIV diagnosis: results of a national study in South Africa.

Woldesenbet SA, Jackson D, Goga AE, Crowley S, Doherty T, Mogashoa MM, Dinh TH, Sherman GG. J Acquir Immune Defic Syndr. 2015 Mar 1;68(3):e26-32. doi: 10.1097/QAI.0000000000000460.

Background: Services to diagnose early infant HIV infection should be offered at the 6-week immunization visit. Despite high 6-week immunization attendance, the coverage of early infant diagnosis (EID) is low in many sub-Saharan countries. We explored reasons for such missed opportunities at 6-week immunization visits.

Methods: We used data from 2 cross-sectional surveys conducted in 2010 in South Africa. A national assessment was undertaken among randomly selected public facilities (n = 625) to ascertain procedures for EID. A subsample of these facilities (n = 565) was revisited to assess the HIV status of 4- to 8-week-old infants receiving 6-week immunization. We examined potential missed opportunities for EID. We used logistic regression to assess factors influencing maternal intention to report for EID at 6-week immunization visits.

Results: EID services were available in >95% of facilities and 72% of immunization service points (ISPs). The majority (68%) of ISPs provide EID for infants with reported or documented (on infant's Road-to-Health Chart/booklet-iRtHC) HIV exposure. Only 9% of ISPs offered provider-initiated counseling and testing for infants of undocumented/unknown HIV exposure. Interviews with self-reported HIV-positive mothers at ISPs revealed that only 55% had their HIV status documented on their iRtHC and 35% intended to request EID during 6-week immunization. Maternal nonreporting for EID was associated with fear of discrimination, poor adherence to antiretrovirals, and inadequate knowledge about mother-to-child HIV transmission.

Conclusions: Missed opportunities for EID were attributed to poor documentation of HIV status on iRtHC, inadequate maternal knowledge about mother-to-child HIV transmission, fear of discrimination, and the lack of provider-initiated counseling and testing service for undocumented, unknown, or undeclared HIV-exposed infants.

Abstract  Full-text [free] access                           

Editor’s notes: Early infant diagnosis (EID) in HIV-exposed infants is important for a number of reasons. Most importantly, it allows early identification and antiretroviral treatment of HIV-positive infants, resulting in markedly reduced morbidity and mortality. It also allows objective assessment of the effectiveness of prevention efforts to eliminate mother-to-child transmission. 

In South Africa, EID services are widely available at immunization service points in public primary healthcare facilities, with 68% offering focussed testing of HIV-exposed infants. This strategy relies on maternal reporting or documentation of maternal HIV status on the “infant’s road to health chart” (iRtHC). This study found that neither the iRtHC nor the maternal reporting were used effectively for conveying HIV exposure status of infants to health workers responsible for EID. Nearly half, 45%, of mothers self-reporting HIV-positive status, had no documentation of their positive status on the iRtHC. In addition, very few healthcare facilities offered provider-initiated counselling and testing for infants of unknown HIV exposure status.

HIV-positive mothers were less likely to disclose their HIV status at six-week immunisation visits if they had limited knowledge of risk of transmission to their child, had missed doses of maternal or infant antiretroviral therapy or reported fear of discrimination and stigma. These results suggest that improving EID requires improving identification of HIV-exposed infants at the six-week immunisation visit and improving maternal education about infant testing during antenatal care. Other strategies include reducing stigma and discrimination through community-level educational campaigns, improving privacy at immunisation facilities and improving provider-initiated counselling and testing of all infants with undocumented or unknown HIV status.

Africa
South Africa
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Assessing risk behaviour and uptake of HIV care using an online network among MSM in Latin America

Engagement in HIV care and sexual transmission risk behavior among men who have sex with men using online social/sexual networking in Latin America.

Magidson JF, Biello KB, Safren SA, Rosenberger JG, Novak DS, Mayer KH, Mimiaga MJ. AIDS Care. 2015 Mar 4:1-8. [Epub ahead of print]

HIV/AIDS in Latin America is concentrated among men who have sex with men (MSM). However, accurate estimates of engagement in HIV care in this population can be difficult to ascertain because many do not self-identify as MSM. Given evidence of decreased HIV transmissibility in the context of antiretroviral therapy (ART) adherence, identifying individuals not in care who are engaging in HIV transmission risk behavior is crucial for secondary prevention. Primary aims of this study were to examine engagement in care from testing to ART adherence among MSM using online social/sexual networking across Latin America, and whether individuals not in care at each step reported greater sexual transmission risk behavior than those in care. In the overall sample (n = 28 779), approximately 75% reported ever being tested for HIV, and 9% reported having received an HIV diagnosis. Among known HIV-infected individuals, 20% reported not being in care, 30% reported not taking ART, and 55% reported less than 100% ART adherence. Over one-third of HIV-infected individuals reported sexual HIV transmission risk behavior, defined as unprotected anal intercourse (UAI) with a male partner of different/unknown HIV serostatus in the past three months. HIV-infected individuals not engaged in care more often reported UAI compared to those in care (OR = 1.29; 95% CI = 1.01-1.66). Although not statistically significant, HIV-infected individuals not on ART more often reported UAI compared to those on ART (OR = 1.18; 95% CI = 0.94-1.47). Individuals who reported less than 100% ART adherence more often reported UAI compared to individuals with 100% adherence (OR = 1.55; 95% CI = 1.26-1.90). Findings demonstrate that a substantial portion of HIV-infected MSM in Latin America who are likely not virologically suppressed from lack of ART use or adherence report sexual HIV transmission risk. Tailoring secondary HIV prevention for MSM in Latin America who are not in HIV care or adherent to ART may be warranted.

Abstract access

Editor’s notes: The prevalence of HIV among gay men and other men who have sex with men in Latin America and the Caribbean is among the highest in the world. Stigma and discrimination towards gay men and other men who have sex with men  in these settings mean that many do not reveal their sexual preference, do not acknowledge their HIV risk, and do not access HIV diagnosis, care and treatment. This paper describes a large cross-sectional study of almost 30 000 gay men and other men who have sex with men from 17 countries in Latin America, recruited via a social/sexual networking website that they had recently used. The study highlights the substantial difficulty in fully engaging gay men and other men who have sex with men living with HIV, into treatment and care services in this region. This in turn contributes to high HIV prevalence and incidence, through unsafe sexual behaviour and unsuppressed viral load in gay men and other men who have sex with men living with HIV. The authors note that the highest proportion of participants receiving HIV care lived in Brazil, where national efforts have been made to reduce homophobia and to include gay men and other men who have sex with men in HIV prevention initiatives. Similar efforts are required in other Latin American countries if their high levels of HIV transmission in these communities, are to be reduced. This includes innovative methods such as using social networking sites as a platform for delivering programmes.  

Latin America
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Barriers and facilitators of safer sexual behaviour for people living with HIV on ART

Intimacy versus isolation: a qualitative study of sexual practices among sexually active HIV-infected patients in HIV care in Brazil, Thailand, and Zambia.

Closson EF, Mimiaga MJ, Sherman SG, Tangmunkongvorakul A, Friedman RK, Limbada M, Moore AT, Srithanaviboonchai K, Alves CA, Roberts S, Oldenburg CE, Elharrar V, Mayer KH, Safren SA, HPTN063 study team. PLoS One. 2015 Mar 20;10(3):e0120957. doi: 10.1371/journal.pone.0120957. eCollection 2015.

The success of global treatment as prevention (TasP) efforts for individuals living with HIV/AIDS (PLWHA) is dependent on successful implementation, and therefore the appropriate contribution of social and behavioral science to these efforts. Understanding the psychosocial context of condomless sex among PLWHA could shed light on effective points of intervention. HPTN 063 was an observational mixed-methods study of sexually active, in-care PLWHA in Thailand, Zambia, and Brazil as a foundation for integrating secondary HIV prevention into HIV treatment. From 2010-2012, 80 qualitative interviews were conducted with PLWHA receiving HIV care and reported recent sexual risk. Thirty men who have sex with women (MSW) and 30 women who have sex with men (WSM) participated in equal numbers across the sites. Thailand and Brazil also enrolled 20 biologically-born men who have sex with men (MSM). Part of the interview focused on the impact of HIV on sexual practices and relationships. Interviews were recorded, transcribed, translated into English and examined using qualitative descriptive analysis. The mean age was 25 (SD = 3.2). There were numerous similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Participants had a high degree of HIV transmission risk awareness and practiced some protective sexual behaviors such as reduced sexual activity, increased use of condoms, and external ejaculation. Themes related to risk behavior can be categorized according to struggles for intimacy and fears of isolation, including: fear of infecting a sex partner, guilt about sex, sexual communication difficulty, HIV-stigma, and worry about sexual partnerships. Emphasizing sexual health, intimacy and protective practices as components of nonjudgmental sex-positive secondary HIV prevention interventions is recommended. For in-care PLWHA, this approach has the potential to support TasP. The overlap of themes across groups and countries indicates that similar intervention content may be effective for a range of settings.

Abstract   Full-text [free] access

Editor’s notes: Antiretroviral therapy has transformed the lives of many people living with HIV, holding the promise of sustaining health well into older age. Yet, as the authors of this paper remind us, HIV remains a stigmatised condition. Because of the fear and prejudice which continue to surround HIV, living with the infection while on antiretroviral therapy remains challenging not least because of its impact on intimate relationships. Using qualitative data from three very different cultural settings, the authors illustrate the continuing impact of HIV infection on the lives of people taking antiretroviral therapy. Many people in the study were keen to reduce the risk of infecting others through risky sexual behaviour. As a consequence, some struggled to establish and sustain intimate relationships trapped in feelings of shame about their infection and guilt about sexual enjoyment. The findings in this paper are not new. But what is interesting is how similar the experience of women and men living with HIV was across the different settings. As the health of more and more people living with HIV is sustained through antiretroviral therapy, there is a continuing and urgent need for programmes that address the fears and concerns that they may have about sexual behaviour. 

Africa, Asia, Latin America
Brazil, Thailand, Zambia
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How policies can fuel stigma

Assessment of policy and access to HIV prevention, care, and treatment services for men who have sex with men and for sex workers in Burkina Faso and Togo.

Duvall S, Irani L, Compaore C, Sanon P, Bassonon D, Anato S, Agounke J, Hodo A, Kugbe Y, Chaold G, Nigobora B, MacInnis R. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S189-97. doi: 10.1097/QAI.0000000000000450.

Background: In Burkina Faso and Togo, key populations of men who have sex with men (MSM) and sex workers (SW) have a disproportionately higher HIV prevalence. This study analyzed the 2 countries' policies impacting MSM and SW; to what extent the policies and programs have been implemented; and the role of the enabling environment, country leadership, and donor support.

Methods: The Health Policy Project's Policy Assessment and Advocacy Decision Model methodology was used to analyze policy and program documents related to key populations, conduct key informant interviews, and hold stakeholder meetings to validate the findings.

Results: Several policy barriers restrict MSM/SW from accessing services. Laws criminalizing MSM/SW, particularly anti-solicitation laws, result in harassment and arrests of even nonsoliciting MSM/SW. Policy gaps exist, including few MSM/SW-supportive policies and HIV prevention measures, e.g., lubricant not included in the essential medicines list. The needs of key populations are generally not met due to policy gaps around MSM/SW participation in decision-making and funding allocation for MSM/SW-specific programming. Misaligned policies, e.g., contradictory informed consent laws and protocols, and uneven policy implementation, such as stockouts of sexually transmitted infection kits, HIV testing materials, and antiretrovirals, undermine evidence-based policies. Even in the presence of a supportive donor and political community, public stigma and discrimination (S&D) create a hostile enabling environment.

Conclusions: Policies are needed to address S&D, particularly health care provider and law enforcement training, and to authorize, fund, guide, and monitor services for key populations. MSM/SW participation and development of operational guidelines can improve policy implementation and service uptake.

Abstract access 

Editor’s notes: This paper summarizes an interesting policy analysis of approaches to the provision of HIV services for gay men and other men who have sex with men and sex workers in Togo and Burkina Faso. Both countries are experiencing similar HIV epidemics, categorised as ‘mixed’ with high HIV prevalence among key populations nested within a generalised HIV epidemic. The policy analyses focus on assessing the ‘enabling’ environment defined as policies and programmes for gay men and other men who have sex with men and sex workers that support or hinder HIV prevention and treatment programming. The analysis clearly illustrates the importance of an enabling environment to facilitate use of programmes as well as shaping attitudes towards gay men and other men who have sex with men and sex workers.  Findings illustrate similar policy environments across both countries. While there are no specific laws preventing gay men and other men who have sex with men and sex workers using services, laws that criminalise sex between men or the exchange of sex result in people being harassed. Or laws are wrongly applied by police and discourage people from using services for fear of harassment and negative attitudes of health workers. Community-based organisations led by gay men and other men who have sex with men are not allowed to participate in developing national HIV strategies, which results in programmes not being tailored to specific population needs. The study clearly illustrates the gap between policy and practice. Even when a policy exists supporting a focussed activity for gay men and other men who have sex with men or sex workers, this is not implemented because of lack of appropriate implementation mechanisms. The paper provides important insights into what are the priorities for advocacy and policy development for gay men and other men who have sex with men and sex workers and calls for more research to illuminate the full range of barriers to services. Any advocacy efforts need to be accompanied by education campaigns to reduce stigma and discrimination against gay men and other men who have sex with men and sex workers. 

Africa
Burkina Faso, Togo
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Stigma, alcohol dependence and consulting traditional doctors associated with non-adherence to ART

Incomplete adherence among treatment-experienced adults on antiretroviral therapy in Tanzania, Uganda and Zambia.

Denison JA, Koole O, Tsui S, Menten J, Torpey K, van Praag E, Mukadi YD, Colebunders R, Auld AF, Agolory S, Kaplan JE, Mulenga M, Kwesigabo GP, Wabwire-Mangen F, Bangsberg DR. AIDS. 2015 Jan 28;29(3):361-71. doi: 10.1097/QAD.0000000000000543.

Objectives: To characterize antiretroviral therapy (ART) adherence across different programmes and examine the relationship between individual and programme characteristics and incomplete adherence among ART clients in sub-Saharan Africa.

Design: A cross-sectional study.

Methods: Systematically selected ART clients (≥18 years; on ART ≥6 months) attending 18 facilities in three countries (250 clients/facility) were interviewed. Client self-reports (3-day, 30-day, Case Index ≥48 consecutive hours of missed ART), healthcare provider estimates and the pharmacy medication possession ratio (MPR) were used to estimate ART adherence. Participants from two facilities per country underwent HIV RNA testing. Optimal adherence measures were selected on the basis of degree of association with concurrent HIV RNA dichotomized at less than or greater/equal to 1000 copies/ml. Multivariate regression analysis, adjusted for site-level clustering, assessed associations between incomplete adherence and individual and programme factors.

Results: A total of 4489 participants were included, of whom 1498 underwent HIV RNA testing. Nonadherence ranged from 3.2% missing at least 48 consecutive hours to 40.1% having an MPR of less than 90%. The percentage with HIV RNA at least 1000 copies/ml ranged from 7.2 to 17.2% across study sites (mean = 9.9%). Having at least 48 consecutive hours of missed ART was the adherence measure most strongly related to virologic failure. Factors significantly related to incomplete adherence included visiting a traditional healer, screening positive for alcohol abuse, experiencing more HIV symptoms, having an ART regimen without nevirapine and greater levels of internalized stigma.

Conclusion: Results support more in-depth investigations of the role of traditional healers, and the development of interventions to address alcohol abuse and internalized stigma among treatment-experienced adult ART patients.

Abstract access

Editor’s notes: Antiretroviral therapy (ART) non-adherence is a strong predictor of incomplete viral suppression, disease progression and mortality in people living with HIV. Declining adherence rates over long-term follow-up of people on ART have been illustrated in a number of observational studies in both low- and high-income settings. This multi-country study gives valuable insight into the challenges that treatment-experienced people living with HIV in low-income countries face on a daily basis. Incomplete adherence was found to be associated with a number of social and behavioural factors. These include internalised stigma, alcohol dependence, low levels of social support and consulting a traditional healer/herbalist. The factor most strongly associated with incomplete adherence was visiting a traditional healer because of HIV. The data contribute to the growing evidence on the role that traditional healers may have in care-seeking behaviours and influencing sustained ART adherence. Findings from this study corroborate research from other studies that alcohol abuse and HIV stigma are broad and consistent correlates of ART adherence. The study also highlights the variability of existing adherence measures and the need for accurate programme-level methods for assessing pill-taking behaviour in order to inform programme strategies and assess impact.

Improving adherence and thereby longer-term healthy outcomes for people living with HIV requires programmatic activities to address alcohol dependence and internalised stigma among treatment-experienced adults. Greater understanding of the role that traditional healers/herbalists play in how people living with HIV manage their infection is also needed to support life-long ART adherence in sub-Saharan Africa.

Africa
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People who inject drugs and the effects of stigma on HIV treatment

A tale of two cities: Stigma and health outcomes among people with HIV who inject drugs in St. Petersburg, Russia and Kohtla-Jarve, Estonia.

Burke SE, Calabrese SK, Dovidio JF, Levina OS, Uuskula A, Niccolai LM, Abel-Ollo K, Heimer R. Soc Sci Med. 2015 Feb 16;130C:154-161. doi: 10.1016/j.socscimed.2015.02.018. [Epub ahead of print]

Experiences of stigma are often associated with negative mental and physical health outcomes. The present work tested the associations between stigma and health-related outcomes among people with HIV who inject drugs in Kohtla-Jarve, Estonia and St. Petersburg, Russia. These two cities share some of the highest rates of HIV outside of sub-Saharan Africa, largely driven by injection drug use, but Estonia has implemented harm reduction services more comprehensively. People who inject drugs were recruited using respondent-driven sampling; those who indicated being HIV-positive were included in the present sample (n = 381 in St. Petersburg; n = 288 in Kohtla-Jarve). Participants reported their health information and completed measures of internalized HIV stigma, anticipated HIV stigma, internalized drug stigma, and anticipated drug stigma. Participants in both locations indicated similarly high levels of all four forms of stigma. However, stigma variables were more strongly associated with health outcomes in Russia than in Estonia. The St. Petersburg results were consistent with prior work linking stigma and health. Lower barriers to care in Kohtla-Jarve may help explain why social stigma was not closely tied to negative health outcomes there. Implications for interventions and health policy are discussed.

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Editor’s notes: This study provides extremely important evidence on the impact of anticipated and felt stigma in relation to HIV and drug use on health outcomes among people who inject drugs in the context of high prevalence of HIV. People who inject drugs in both Russia and Estonia are highly marginalised. Previous studies indicate prevalence to be as high as 90% in Kohtla-Järve and incidence of five per 100 person-years in St Petersburg. Despite their close geographical proximity the two cities are framed by very different social and structural policies that enable and disable the provision of HIV prevention programmes to people who inject drugs. In Estonia, the provision of needle–syringe programmes and opioid substitution therapy is widespread and supported by the government. In Russia the limited harm reduction programmes are provided by non-governmental organisations with little or no support from government. Ambiguous drug policies often prohibit the use of needle –syringe programmes on the grounds they promote drug use. Opioid substitution therapy (OST) is not prescribed and people who inject drugs are viewed as potential criminals by police. People who inject drugs are frequently put under surveillance through a mandatory registration system by police and drug treatment (narcology) clinics. High levels of both internalised and anticipated stigma in relation to HIV and drug use were found in both sites. In Estonia this was not associated with poorer HIV outcomes including access to HIV care, CD4 count or self-reported HIV symptoms. Conversely in St Petersburg, internalised stigma associated with drug use was associated with lower CD4 count, reduced access to HIV care and increased HIV symptoms. This underscores the effectiveness of low-threshold HIV prevention and treatment services for people who inject drugs in the treatment of HIV, despite the existence of other social and cultural norms that stigmatise HIV and drug use. This study demonstrates the effect of stigma on HIV outcomes. However, further research is needed to understand the mechanisms through which stigma interplays with other social and structural factors, such as migration, poverty and criminalisation, to impact on health outcomes among people who inject drugs.

The study has clear policy implications. They include the need for structural interventions such as increased government support for harm reduction. These are necessary to prevent the reproduction of HIV and drug-use related stigma and its harmful impacts. Shorter-term programmes are required in Russia, including the urgent scale up of harm reduction activities and HIV treatment and care for people who inject drugs as well as the provision of inter-personal support to assist people who inject drugs in facing stigma within health services. 

Europe
Estonia, Russian Federation
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