Articles tagged as "Stigma and social exclusion"

Staying on Option B+: why post-partum women are dropping out of HIV care in a Johannesburg clinic

What they wanted was to give birth; nothing else: barriers to retention in option B+ HIV care among postpartum women in South Africa.

Clouse K, Schwartz S, Van Rie A, Bassett J, Yende N, Pettifor A. J Acquir Immune Defic Syndr. 2014 Sep 1;67(1):e12-8. doi: 10.1097/QAI.0000000000000263.

Background: Women initiating antiretroviral therapy during pregnancy have high rates of dropout, particularly after delivery. We aimed to identify challenges to postpartum retention in care under Option B+, which expands antiretroviral therapy access to all HIV-positive pregnant women regardless of CD4 count.

Methodology: We performed 2 semi-structured interviews (SSI, n = 50) and 1 focus group discussion (n = 8) with HIV-positive women at Witkoppen Health and Welfare Centre, a primary care facility in Johannesburg, South Africa, that is one of the only clinics offering Option B+ in South Africa.

Results: Fifty women completed the SSI before delivery, and 48 (96%) completed the second SSI within 3 months of delivery. Median age was 28 years (interquartile range: 26-34); most women worked (62%) or had worked in the previous year (18%). Postpartum women attending HIV care perceived that barriers to HIV care after delivery among other women included the belief that mothers care more about the baby's health than their own (29.2%, 14/48), women were "ignorant" or "irresponsible" (16.7%, 8/48), negative clinic staff treatment (12.5%, 6/48), and denial or lack of disclosure of HIV status (10.4% each, 5/48). Experienced barriers included lack of money (18.0%, 9/50), work conflict (6.0%, 3/50), and negative staff treatment (6.0%, 3/50). During the focus group discussion, 3 main themes emerged: conflict with work commitment, negative treatment from health-care workers, and lack of disclosure related to stigma.

Conclusions: We identified a complex set of interconnected barriers to retaining postpartum women in HIV care under Option B+, including structural, personal, and societal barriers. The importance of postpartum HIV care for the mother's own health must be embraced by health-care workers and public health programs.

Abstract access 

Editor’s notes: This paper addresses a key knowledge gap which is, why do post-partum women living with HIV drop out of HIV care, despite having the opportunity to access ongoing HIV care? This paper presents the findings of a qualitative study conducted with women in a Johannesburg clinic who are being offered option B+. Option B+, seeks to initiate all HIV-positive pregnant women on lifelong highly active antiretroviral therapy (ART) regardless of CD4 count. Its success depends on the proportion of women who are retained in care and continue to adhere to treatment.

While the study found that very few women admitted that they themselves would stop taking their ART, they cited multiple reasons for other women to stop doing so. Many of these reasons have been discussed before, such as prioritising the health of their baby and having been harshly treated by healthcare workers during their delivery. A key issue identified in the paper is that once women have given birth they describe no longer having a ‘legitimate’ reason, in this case antenatal care, to continue attending a clinic. So we learn that being pregnant provides a cover to legitimise clinic attendance and women are able to receive HIV care without the risk of arousing suspicion. This is revealing about the ongoing HIV stigma and the challenges that a woman faces in explaining any regular visits to a healthcare facility to partners, family members, employers and others within their community. This illustrates the complex negotiations involved for many women in leaving their work commitments, formal or informal, to regularly attend an HIV clinic.

This paper is valuable because it shows us that unfortunately, even if costs can be waived, access may still be impeded by the persistent constraints involved in the management of non-disclosure. We may also learn a valuable methodological lesson from this study. To access information and opinions about drop-out and disengagement in HIV care, research may be more effective if studies allow individuals to talk about such issues indirectly through other people’s experiences rather than their own. This will address issues of social desirability bias in clinic based research. 

Africa
South Africa
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More data needed from routine programme data on antiretroviral therapy cascade outcomes among female sex workers

Antiretroviral therapy uptake, attrition, adherence and outcomes among HIV-infected female sex workers: a systematic review and meta-analysis.

Mountain E, Mishra S, Vickerman P, Pickles M, Gilks C, Boily MC. PLoS One. 2014 Sep 29;9(9):e105645. doi: 10.1371/journal.pone.0105645. eCollection 2014.

Purpose: We aimed to characterize the antiretroviral therapy (ART) cascade among female sex workers (FSWs) globally.

Methods: We systematically searched PubMed, Embase and MEDLINE in March 2014 to identify studies reporting on ART uptake, attrition, adherence, and outcomes (viral suppression or CD4 count improvements) among HIV-infected FSWs globally. When possible, available estimates were pooled using random effects meta-analyses (with heterogeneity assessed using Cochran's Q test and I2 statistic).

Results: 39 studies, reporting on 21 different FSW study populations in Asia, Africa, North America, South America, and Central America and the Caribbean, were included. Current ART use among HIV-infected FSWs was 38% (95% CI: 29%-48%, I2 = 96%, 15 studies), and estimates were similar between high-, and low- and middle-income countries. Ever ART use among HIV-infected FSWs was greater in high-income countries (80%; 95% CI: 48%-94%, I2 = 70%, 2 studies) compared to low- and middle-income countries (36%; 95% CI: 7%-81%, I2 = 99%, 3 studies). Loss to follow-up after ART initiation was 6% (95% CI: 3%-11%, I2 = 0%, 3 studies) and death after ART initiation was 6% (95% CI: 3%-11%, I2 = 0%, 3 studies). The fraction adherent to ≥95% of prescribed pills was 76% (95% CI: 68%-83%, I2 = 36%, 4 studies), and 57% (95% CI: 46%-68%, I2 = 82%, 4 studies) of FSWs on ART were virally suppressed. Median gains in CD4 count after 6 to 36 months on ART, ranged between 103 and 241 cells/mm3 (4 studies).

Conclusions: Despite global increases in ART coverage, there is a concerning lack of published data on HIV treatment for FSWs. Available data suggest that FSWs can achieve levels of ART uptake, retention, adherence, and treatment response comparable to that seen among women in the general population, but these data are from only a few research settings. More routine programme data on HIV treatment among FSWs across settings should be collected and disseminated.

Abstract  Full-text [free] access

Editor’s notes: Female sex workers remain a key population for HIV prevention, treatment and care. This is the first paper to systematically review and quantify the HIV treatment cascade among sex workers globally. The review highlights the scarcity of published data on HIV treatment among sex workers. For example, data were identified from only five countries in sub-Saharan Africa (Benin, Burkina Faso, Kenya, Rwanda and Zimbabwe) and a lack of data from routine (non research) settings. Further, most studies presented data on current antiretroviral therapy (ART) or CD4 count at initiation rather than follow-up data on attrition, adherence or viral suppression. The results suggest that research cohorts have been largely successful at enrolling and retaining female sex workers on ART, but there may be an issue with adherence. Adherence, in the few studies where it was measured (usually by self-report or pill counts) was high, and similar to estimates from the general population. But just over half of the participants initiating ART achieved viral suppression in the four studies which looked at this. This indicates scope for improvements in adherence (and adherence measurement) in these populations. This is possibly due to individual-level and structural-level barriers that sex workers face when receiving HIV treatment and care

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Stigma and HIV – the continuing challenge

Persistent HIV-related stigma in rural Uganda during a period of increasing HIV incidence despite treatment expansion.

Chan BT, Weiser SD, Boum Y, Siedner MJ, Mocello AR, Haberer JE, Hunt PW, Martin JN, Mayer KH, Bangsberg DR, Tsai AC. AIDS. 2014 Sep 27. [Epub ahead of print]

Objective: Programme implementers have argued that the increasing availability of antiretroviral therapy (ART) will reduce the stigma of HIV. We analyzed data from Uganda to assess how HIV-related stigma has changed during a period of ART expansion.

Design: Serial cross-sectional surveys.

Methods: We analyzed data from the Uganda AIDS Rural Treatment Outcomes study during 2007-2012 to estimate trends in internalized stigma among people living with HIV (PLHIV) at the time of treatment initiation. We analyzed data from the Uganda Demographic and Health Surveys from 2006 to 2011 to estimate trends in stigmatizing attitudes and anticipated stigma in the general population. We fitted regression models adjusted for sociodemographic characteristics, with year of data collection as the primary explanatory variable.

Results: We estimated an upward trend in internalized stigma among PLHIV presenting for treatment initiation [adjusted b = 0.18; 95% confidence interval (CI), 0.06-0.30]. In the general population, the odds of reporting anticipated stigma were greater in 2011 compared with 2006 [adjusted odds ratio (OR) = 1.80; 95% CI, 1.51-2.13], despite an apparent decline in stigmatizing attitudes (adjusted OR = 0.62; 95% CI, 0.52-0.74).

Conclusion: Internalized stigma has increased over time among PLHIV in the setting of worsening anticipated stigma in the general population. Further study is needed to better understand the reasons for increasing HIV-related stigma in Uganda and its impact on HIV prevention efforts.

Abstract access 

Editor’s notes: This paper provides very useful insights on HIV and stigma. The authors caution that the results may only apply to Uganda, a country where incidence has risen in recent years. However, contrary to their concern, the findings are likely to be more generalizable. As the authors note, social desirability bias may have affected the way people reported potentially stigmatising attitudes: people were sensitised to know what the correct answer was. Or it may be that while an individual may have changed their own attitude, they believe that stigmatising attitudes are prevalent in the wider society. Thus anticipated stigma, fear of disclosure for example, had increased. Many people had believed that the roll-out of antiretroviral therapy would mean an end to HIV stigma, instead we have people fearing that treatment is hiding people living with HIV from public view. This valuable paper describes these processes and highlights the very complex nature of HIV-related stigma; a timely reminder of the continuing challenges in ‘the era of ART expansion’. 

Africa
Uganda
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Making sense of being HIV positive through religion in Papua New Guinea

We call it a virus but I want to say it's the devil inside': redemption, moral reform and relationships with God among people living with HIV in Papua New Guinea.

Kelly-Hanku A, Aggleton P, Shih P. Soc Sci Med. 2014 Aug 19;119C:106-113. doi: 10.1016/j.socscimed.2014.08.020. [Epub ahead of print]

There is growing recognition of the importance of religion and religious beliefs as they relate to the experience of HIV, globally and in Papua New Guinea in particular. Based on 36 in-depth qualitative interviews conducted with people living with HIV receiving HIV antiretroviral therapy in 2008, this paper examines the cultural aetiology of HIV of in Papua New Guinea, the country with the highest reported burden of HIV in the Pacific. Narratives provided drew upon a largely moral framework, which viewed HIV acquisition as a consequence of moral failing and living an un-Christian life. This explanation for suffering viewed the individual as responsible for their condition in much the same way that neo-liberal biomedical discourses do. Moral reform and re-establishing a relationship with God were seen as key actions necessary to effect healing on the material body infected with HIV. Religious understandings of HIV drew upon a pre-existing cultural aetiology of dis-ease and misfortune widespread in Papua New Guinea. Understanding the centrality of Christianity to explanations of disease, and subsequently the actions necessary to bring about health, is essential in order to understand how people with HIV in receipt of antiretroviral therapies internalise biomedical perspectives and reconcile these with Christian beliefs.

Abstract access 

Editor’s notes: This is an insightful paper which reveals how religion and religious belief can impact on the experience of being HIV positive. Drawing on in-depth interviews conducted as part of a mixed-methods study, the authors explored what people from Papua New Guinea (PNG) view as the cause of their illness, and how they respond to their diagnosis. They argue that whilst there has been much anthropological enquiry into religion and HIV in PNG and elsewhere, there has been little attention to the experiences of people living with HIV. In introducing the context the authors highlight the influence of Christianity on everyday life in PNG, which is localised and informed by traditional practices. The findings are deeply illuminating and reveal that the participants understood their illness within moral frameworks. Contagion was explained by “sinful” behaviour, especially promiscuity. Whilst blaming HIV for such moral transgressions has been described elsewhere, these findings reveal that these participants describe their own behaviour in such terms. Responding to their diagnosis involved returning to the church or religious conversion, which created an individual relationship with God that affected healing of the body. These practices could result in lifestyle change and a rejection of previous immoral practices such alcohol and drugs. These narratives contribute to understanding the complexity of meanings that surround HIV. In particular, people from PNG may not consider structural or socio-cultural factors to be the cause of HIV. The authors suggest that in the context of an increasing bio-medicalisation of the response to HIV, a focus on how people live with HIV is very important and needs to take into account religious belief. 

Oceania
Papua New Guinea
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Facing uncertainty – ageing with HIV

Aging with HIV: a model of disability.

Solomon P, O'Brien K, Wilkins S, Gervais N. J Int Assoc Provid AIDS Care. 2014 Aug 22. pii: 2325957414547431. [Epub ahead of print]

The purpose of this qualitative study was to develop a theoretical model describing the disability experienced by older adults living with HIV. Forty nine HIV positive men and women over the age of 50 years participated in in-depth qualitative interviews. Transcribed interviews were analyzed using grounded theory techniques. Uncertainty or worrying about the future was at the core of the model. Components of disability including symptoms and impairments, difficulties with day to day activities and challenges to social participation were experienced in the context of extrinsic or environmental factors (social support, stigma) and intrinsic contextual factors (positive living strategies, age). Time was an overarching component of the model. The model suggests areas for interventions to prevent or reduce disability related to the consequences of aging with HIV and improve overall quality of life.

 Abstract access 

Editor’s notes: This paper is a very welcome addition to the growing body of research on HIV and ageing. Time is highlighted in the findings. Time has been regained (because treatment has kept people alive to grow old) and time is moving too fast (as individuals fear accelerated ageing because of HIV). The authors also highlight the centrality of uncertainty in the lives of the 49 people interviewed. Uncertainty is central to ageing. No-one of us knows quite how well we may remain as we age. However, the interaction between HIV and the ageing process is an added layer of uncertainty. The average age of people in this study was only 56, so they were relatively young, older people. We can expect worries over adequate social support and managing increasing ill-health and disability, will increase as people age. The authors urge us to look at the impact of HIV on older people’s quality of life as a whole, in the design of programmes. This paper is a timely reminder of the social, mental and physical burden HIV continues to impose on people’s lives.

Northern America
Canada
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The burden of HIV: bullying and children from HIV-affected families

Relationships between familial HIV/AIDS and symptoms of anxiety and depression: the mediating effect of bullying victimization in a prospective sample of South African children and adolescents.

Boyes ME, Cluver. J Youth Adolesc. 2014 Jul 5. [Epub ahead of print]

South African children and adolescents living in HIV/AIDS-affected families are at elevated risk of both symptoms of anxiety and depressive symptoms. Poverty and HIV/AIDS-related stigma are additional risk factors for these negative mental health outcomes. Community level factors, such as poverty and stigma, are difficult to change in the short term and identifying additional potentially malleable mechanisms linking familial HIV/AIDS with mental health is important from an intervention perspective. HIV/AIDS-affected children are also at increased risk of bullying victimization. This longitudinal study aimed to determine whether prospective relationships between familial HIV/AIDS and both anxiety symptoms and depressive symptoms operate indirectly via bullying victimization. Adolescents (M = 13.45 years, 56.67 % female, n = 3 515) from high HIV-prevalent (>30 %) communities in South Africa were interviewed and followed-up one year later (n = 3 401, 96.70 % retention). Census enumeration areas were randomly selected from urban and rural sites in two provinces, and door-to-door sampling included all households with a resident child/adolescent. Familial HIV/AIDS at baseline assessment was not directly associated with mental health outcomes 1 year later. However, significant indirect effects operating via bullying victimization were obtained for both anxiety and depression scores. Importantly, these effects were independent of poverty, HIV/AIDS-related stigma, and baseline mental health, which highlight bullying victimization as a potential target for future intervention efforts. The implementation and rigorous evaluation of bullying prevention programs in South African communities may improve mental health outcomes for HIV/AIDS-affected children and adolescents and this should be a focus of future research and intervention.

Abstract access

Editor’s notes: Children from HIV-affected families’ experience of bullying, as described in this paper, provides a very valuable addition to the literature.  The authors note that links between anxiety and depression among adolescents (and others) from HIV-affected families are known.  Indirect impacts which may be very detrimental to adolescent health and wellbeing are less known.  Bullying victimisation can have a long-term impact on educational and social outcomes for young people.  The call for rigorous evaluation of programmes is welcome.  Further work would be valuable to investigate if bullying might increase if a sibling (who may have once attended the same school) of the child had died of AIDS or was living with HIV. The experience of bullying victimisation of orphaned adolescents who are living with HIV themselves also requires further investigation in different contexts.

Africa
South Africa
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Applying theory on stigma to the life histories of children living with HIV

The "moral career" of perinatally HIV-infected children: revisiting Goffman's concept.

Cruz ML, Bastos FI, Darmont M, Dickstein P, Monteiro S. AIDS Care. 2014 Jul 23:1-4. [Epub ahead of print]

HIV-infected children usually live in vulnerable situations, experiencing discrimination and stigma commonly felt by other people living with HIV/AIDS. The present study aims to analyse primary socialisation of HIV-infected children and adolescents recruited from a public health service in Rio de Janeiro (Brazil) as a social process that shapes a new generation of stigmatised and vulnerable persons. Research was informed by an interactionist perspective, focusing on key aspects of HIV-infected children and adolescents life histories under the conceptual frame of Erving Goffman's theories regarding "moral careers". Goffman defines the making of a moral career as the process through which a person learns that she/he possesses a particular attribute, which may lead her/him to be discredited by members of the surrounding society. We have identified aspects of life histories of HIV-vertically infected children and adolescents for each aspect of "moral career" as described by Goffman, relating them to as family structure, the experience of living HIV within the family, and the position and family role of a given subject. The patterns of "moral career" proposed by Goffman in 1963 were useful in identifying components of HIV-related stigma among children and adolescents. These include gender and social disadvantages, difficulty in coping with a child with a potentially severe disease, orphanhood, abandonment, adoption and disclosure of one's HIV serostatus. Primary socialisation of HIV-infected children and adolescents is a key piece of the complex HIV/AIDS-labelling process that could be targeted by interventions aiming to decrease stigma and marginalisation. Health care workers and stakeholders should be committed to ensuring education and guaranteeing the legal rights of this specific population, including the continuous provision of quality health care, full access to school and support to full disclosure of HIV diagnosis.

Abstract access

Editor’s notes: This paper applies Goffman’s theory of ‘moral careers’ to analyse how children and adolescents living with HIV come to be socialised as stigmatised persons. Goffman’s theory identifies the process through which someone becomes defined as possessing a discrediting attribute, and is subsequently discriminated.

The authors collected the life histories of young people living with HIV in Rio de Janeiro, Brazil. Specifically the data were generated through researchers doing clinic observations at one of the city’s public hospitals. They identify four pivotal episodes over the course of an HIV positive young person’s life which socialise them to becoming a stigmatised person. These are: developing symptomatic diseases from an early age; their HIV diagnosis being kept a secret from them; learning of their HIV status as an adolescent having been asymptomatic; and learning about their HIV diagnosis within an orphanage or similar institution. This analysis also illuminates key opportunities to take action and prevent potential damage. The authors consider how, why and when children living with HIV become stigmatised during their early and adolescent lives. Crucially this paper includes important reflections on how children come to stigmatise themselves through absorbing the perceptions of the society within which they are living.  The authors argue that activities are needed, especially delivered by healthcare workers, which focus on these events by providing information and support to young people and their families. Such strategically timed action would positively affect the way these children grow up in their communities.   

Latin America
Brazil
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Mental health concerns similar for HIV-affected and HIV-positive children in Rwanda

HIV and child mental health: a case-control study in Rwanda

Betancourt T, Scorza P, Kanyanganzi F, Fawzi MC, Sezibera V, Cyamatare F, Beardslee W, Stulac S, Bizimana JI, Stevenson A, Kayiteshonga Y. Paediatrics. 2014 Jul 5. [Epub ahead of print]

The global HIV/AIDS response has advanced in addressing the health and well-being of HIV-positive children. Although attention has been paid to children orphaned by parental AIDS, children who live with HIV-positive caregivers have received less attention. This study compares mental health problems and risk and protective factors in HIV-positive, HIV-affected (due to caregiver HIV), and HIV-unaffected children in Rwanda. A case-control design assessed mental health, risk, and protective factors among 683 children aged 10 to 17 years at different levels of HIV exposure. A stratified random sampling strategy based on electronic medical records identified all known HIV-positive children in this age range in 2 districts in Rwanda. Lists of all same-age children in villages with an HIV-positive child were then collected and split by HIV status (HIV-positive, HIV-affected, and HIV-unaffected). One child was randomly sampled from the latter 2 groups to compare with each HIV-positive child per village. HIV-affected and HIV-positive children demonstrated higher levels of depression, anxiety, conduct problems, and functional impairment compared with HIV-unaffected children. HIV-affected children had significantly higher odds of depression (1.68: 95% confidence interval [CI] 1.15-2.44), anxiety (1.77: 95% CI 1.14-2.75), and conduct problems (1.59: 95% CI 1.04-2.45) compared with HIV-unaffected children, and rates of these mental health conditions were similar to HIV-positive children. These results remained significant after controlling for contextual variables. The mental health of HIV-affected children requires policy and programmatic responses comparable to HIV-positive children.

Abstract access

Editor’s notes: The successes of prevention of mother-to-child transmission programmes have led to a substantial increase in the number of HIV-affected children in sub-Saharan Africa. While the physical health trajectory of these children has been the subject of much research, far less is known about their mental health status. In Rwanda investigators found that, relative to HIV-unaffected children, HIV-positive and HIV-affected children both had similarly compromised mental health and functioning. Many of these differences could be explained by the fact that these latter groups were more likely to have experienced the death of a caregiver and not to have their mother as their primary caregiver. These results make us consider not only the need for psychosocial services for the children of HIV-positive adults, but also to consider parity of services regardless of the child’s own HIV status.

Africa
Rwanda
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Intimate partner violence common among microbicide trial participants

Hidden harms: women's narratives of intimate partner violence in a microbicide trial, South Africa.

Stadler J, Delany-Moretlwe S, Palanee T, Rees H. Soc Sci Med. 2014 Jun;110:49-55. doi: 10.1016/j.socscimed.2014.03.021. Epub 2014 Mar 22.

In a context of high rates of intimate partner violence (IPV), trials of female-controlled technologies for HIV prevention such as microbicides may increase the possibility of social harms. Seeking to explore the relationship between IPV and microbicide use further, this paper documents women’s narratives of participating in the Microbicide Development Program (MDP) trial in Johannesburg, South Africa, and experiences of partner violence and conflict. A social science sub-study, nested within the trial, was conducted between September 2005 and August 2009, and 401 serial in-depth-interviews were undertaken with 150 women. Using coded interview transcripts, we describe the distribution of IPV and the possible association thereof with microbicide gel use and trial participation. More than a third of these 150 women reported IPV, of which half the cases were related to involvement in the trial. In their narratives, those women reporting IPV cast their partners as authoritarian, controlling and suspicious and reported verbal abuse, abandonment, and in some cases, beatings. Shared experiences of everyday violence shaped women’s feelings of unease about revealing their participation in the trial to intimate partners and attempted concealment further contributed to strains and conflict within relationships. Our findings point to the role of social scientific enquiry in identifying the less obvious, hidden negative impacts of participation in a clinical trial therefore exposing limitations in the biomedical construction of ‘social harms’, as well as the implications thereof for potential future use outside the clinical trial setting.

Abstract access 

Editor’s notes: Violence within intimate partnerships is common globally. Longitudinal research from South Africa and Uganda has shown that women in violent relationships are at increased risk of acquiring HIV infection. This study presents qualitative data, collected as part of a nested study of 150 women in Orange Farm, South Africa who participated in the Microbicide Development Programme (MDP) trial. Although experiences of violence were not framed as a social harm in the trial, or actively explored in the research, violence did emerge as an important issue. More than a third of respondents were living with men who were physically or psychologically violent and/or controlling. The violent events resulting from trial participation were primarily psychological, along with some incidents of physical violence.

Women described using a range of strategies to try to minimise the risk of violence that could result from being part of the trial. Some women were very adept at negotiating gel use with a controlling, violent or potentially violent partner.  The pervasiveness of violence and its links with HIV vulnerability illustrates the challenges of reducing women's risk of HIV acquisition. The findings suggests that female initiated technologies, such as microbicides, are urgently needed, but that broader programmes, to address violence within relationships, will also be important. The findings also raise issues of how to conceptualise and respond to such forms of social harms within clinical trials. The findings suggest that trialists need to be better equipped to deal with IPV, for example by providing counselling and social and legal referral, as well as possibly supporting the sharing of successful strategies between women. It also highlights the potential synergies that could be obtained by more effectively bringing together biomedical developments, such as microbicides, along with broader development initiatives, that seek to prevent violence within relationships. 

Africa
South Africa
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Social intolerance increases risky sexual behaviour

HIV-related social intolerance and risky sexual behavior in a high HIV prevalence environment.

Delavande A, Sampaio M, Sood N. Soc Sci Med. 2014 Apr 13;111C:84-93. doi: 10.1016/j.socscimed.2014.04.011. [Epub ahead of print]

Although most countries state that fighting social intolerance against persons with HIV is part of their national HIV strategy, the impact of reducing intolerance on risky sexual behavior is largely unknown. In this paper, we estimate the effect of social intolerance against HIV+ persons on risky sexual behavior in rural Malawi using data from roughly 2 000 respondents from the 2004 and 2006 waves of the Malawi Longitudinal Study of Families and Health (MLSFH). The effect of social intolerance on risky behavior is a priori ambiguous. On the one hand, higher social intolerance or stigma can lead people to disassociate from the stigmatized group and hence promote risky behavior. On the other hand, intolerance can be viewed as a social tax on being HIV+ and thus higher intolerance may reduce risky behavior. We find that a decrease in social intolerance is associated with a decrease in risky behavior, including fewer partners and a lower likelihood of having extra-marital relations. This effect is mainly driven by the impact of social intolerance on men. Overall the results suggest that reducing social intolerance might not only benefit the HIV positive but might also forestall the spread of HIV.

Abstract access 

Editor’s notes: Social intolerance is the unwillingness of certain groups to tolerate ideas or behaviour different from their own. The focus of this paper on social intolerance in Malawi is timely, given the moves in certain countries to put in place legislation to sanction what are perceived to be ‘deviant behaviours’. The authors show that a greater tolerance of people living with HIV encourages safer sexual behaviour. These findings suggest that efforts to address intolerance, stigma and discrimination may have a more lasting impact than legislation, which may drive marginalised groups underground. 

Africa
Malawi
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