Articles tagged as "Structural determinants and vulnerability"

Patient navigators and financial incentives have no effect on HIV viral suppression in people with substance use disorders

Effect of patient navigation with or without financial incentives on viral suppression among hospitalized patients with HIV infection and substance use: a randomized clinical trial.  

Metsch LR, Feaster DJ, Gooden L, Matheson T, Stitzer M, Das M, Jain MK, Rodriguez AE, Armstrong WS, Lucas GM, Nijhawan AE, Drainoni ML, Herrera P, Vergara-Rodriguez P, Jacobson JM, Mugavero MJ, Sullivan M, Daar ES, McMahon DK, Ferris DC, Lindblad R, VanVeldhuisen P, Oden N, Castellon PC, Tross S, Haynes LF, Douaihy A, Sorensen JL, Metzger DS, Mandler RN, Colfax GN, del Rio C. JAMA. 2016 Jul 12;316(2):156-70. doi: 10.1001/jama.2016.8914.

Importance: Substance use is a major driver of the HIV epidemic and is associated with poor HIV care outcomes. Patient navigation (care coordination with case management) and the use of financial incentives for achieving predetermined outcomes are interventions increasingly promoted to engage patients in substance use disorders treatment and HIV care, but there is little evidence for their efficacy in improving HIV-1 viral suppression rates.

Objective: To assess the effect of a structured patient navigation intervention with or without financial incentives to improve HIV-1 viral suppression rates among patients with elevated HIV-1 viral loads and substance use recruited as hospital inpatients.

Design, setting, and participants: From July 2012 through January 2014, 801 patients with HIV infection and substance use from 11 hospitals across the United States were randomly assigned to receive patient navigation alone (n = 266), patient navigation plus financial incentives (n = 271), or treatment as usual (n = 264). HIV-1 plasma viral load was measured at baseline and at 6 and 12 months.

Interventions: Patient navigation included up to 11 sessions of care coordination with case management and motivational interviewing techniques over 6 months. Financial incentives (up to $1160) were provided for achieving targeted behaviors aimed at reducing substance use, increasing engagement in HIV care, and improving HIV outcomes. Treatment as usual was the standard practice at each hospital for linking hospitalized patients to outpatient HIV care and substance use disorders treatment.

Main outcomes and measures: The primary outcome was HIV viral suppression (200 copies/mL) relative to viral nonsuppression or death at the 12-month follow-up.

Results: Of 801 patients randomized, 261 (32.6%) were women (mean [SD] age, 44.6 years [10.0 years]). There were no differences in rates of HIV viral suppression versus nonsuppression or death among the 3 groups at 12 months. Eighty-five of 249 patients (34.1%) in the usual-treatment group experienced treatment success compared with 89 of 249 patients (35.7%) in the navigation-only group for a treatment difference of 1.6% (95% CI, -6.8% to 10.0%; P = .80) and compared with 98 of 254 patients (38.6%) in the navigation-plus-incentives group for a treatment difference of 4.5% (95% CI -4.0% to 12.8%; P = .68). The treatment difference between the navigation-only and the navigation-plus-incentives group was -2.8% (95% CI, -11.3% to 5.6%; P = .68).

Conclusions and relevance: Among hospitalized patients with HIV infection and substance use, patient navigation with or without financial incentives did not have a beneficial effect on HIV viral suppression relative to nonsuppression or death at 12 months vs treatment as usual. These findings do not support these interventions in this setting. TRIAL REGISTRATION: Identifier: NCT01612169.

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Editor’s notes: Substance use in people living with HIV has consistently been shown to be associated with poor clinical outcomes. Within this population, management often requires a combination of treatment for both HIV and substance use disorders. It is evident that it is the poor engagement in one or both of these treatment approaches that contributes significantly to poor clinical outcomes. The author’s group aimed to fill a gap in current evidence and explore whether two activities, patient navigation and financial incentives, could potentially motivate engagement with both treatment approaches and ultimately improve HIV viral suppression.

This study tested, among people living with HIV in hospital,  with substance use disorders, six months of patient navigation alone (care co-ordination and case management), or six months of patient navigation alongside a financial incentive plan. While overall uptake and retention to the programme schedules were high, no differences in HIV-1 viral suppression rates (which were generally poor) or death by 12 months were noted.

One factor that must be highlighted is that the participation in actual substance use treatment programmes post hospital discharge was low across all groups (average 24.8%), primarily due to a lack of available services in the regions. It may be that the programme may have been more effective in a different population of people already established in substance use treatment programmes, or if treatment had been more easily accessible.

The study serves as a reminder that such key populations are extremely vulnerable with a number of comorbidities and competing priorities. While not supporting health care navigation or financial incentives in their defined setting, the study findings emphasise a need to develop and tailor, cost-effective activities to improve health outcomes in this group.

Northern America
United States of America
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Demand-side activities are essential for achieving population level impact of HIV prevention tools

Interventions to strengthen the HIV prevention cascade: a systematic review of reviews.

Krishnaratne S, Hensen B, Cordes J, Enstone J, Hargreaves JR. Lancet HIV. 2016 Jul;3(7):e307-17. doi: 10.1016/S2352-3018(16)30038-8.

Background: Much progress has been made in interventions to prevent HIV infection. However, development of evidence-informed prevention programmes that translate the efficacy of these strategies into population effect remain a challenge. In this systematic review, we map current evidence for HIV prevention against a new classification system, the HIV prevention cascade.

Methods: We searched for systematic reviews on the effectiveness of HIV prevention interventions published in English from Jan 1, 1995, to July, 2015. From eligible reviews, we identified primary studies that assessed at least one of: HIV incidence, HIV prevalence, condom use, and uptake of HIV testing. We categorised interventions as those seeking to increase demand for HIV prevention, improve supply of HIV prevention methods, support adherence to prevention behaviours, or directly prevent HIV. For each specific intervention, we assigned a rating based on the number of randomised trials and the strength of evidence.

Findings: From 88 eligible reviews, we identified 1964 primary studies, of which 292 were eligible for inclusion. Primary studies of direct prevention mechanisms showed strong evidence for the efficacy of pre-exposure prophylaxis (PrEP) and voluntary medical male circumcision. Evidence suggests that interventions to increase supply of prevention methods such as condoms or clean needles can be effective. Evidence arising from demand-side interventions and interventions to promote use of or adherence to prevention tools was less clear, with some strategies likely to be effective and others showing no effect. The quality of the evidence varied across categories.

Interpretation: There is growing evidence to support a number of efficacious HIV prevention behaviours, products, and procedures. Translating this evidence into population impact will require interventions that strengthen demand for HIV prevention, supply of HIV prevention technologies, and use of and adherence to HIV prevention methods.

Abstract  Full-text [free] access

Editor’s notes: Demand, supply and use of programmes are crucial for the uptake and effective use of HIV prevention strategies. This paper presents an impressive undertaking in which the authors conducted a review of systematic reviews on the evidence for the effectiveness of HIV prevention programmes across the multiple steps in an HIV prevention cascade. This particular prevention cascade allocates programmes into demand-side, supply-side, adherence, and direct HIV prevention technologies. This was published in a separate paper in conjunction with this review. The review found that there is strong evidence with regards to which direct HIV prevention technologies are efficacious, as well as maps where adherence and supply-side programmes have been effective. A primary gap was noted on the demand-side of the cascade (e.g. information, education and communication, and peer-based activities to increase demand for medical male circumcision) where studies have not resulted in reducing HIV incidence or prevalence. There remains a need to understand why, despite supply, there is low uptake of some HIV prevention strategies, and for evaluation of novel activities to increase demand.  

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Negative police activity a structural determinant of HIV

Policing practices as a structural determinant for HIV among sex workers: a systematic review of empirical findings.

Footer KH, Silberzahn BE, Tormohlen KN, Sherman SG. J Int AIDS Soc. 2016 Jul 18;19(4 Suppl 3):20883. doi: 10.7448/IAS.19.4.20883. eCollection 2016.

Introduction: Sex workers are disproportionately infected with HIV worldwide. Significant focus has been placed on understanding the structural determinants of HIV and designing related interventions. Although there is growing international evidence that policing is an important structural HIV determinant among sex workers, the evidence has not been systematically reviewed.

Methods: We conducted a systematic review of quantitative studies to examine the effects of policing on HIV and STI infection and HIV-related outcomes (condom use; syringe use; number of clients; HIV/STI testing and access) among cis and trans women sex workers. Databases included PubMed, Embase, Scopus, Sociological Abstracts, Popline, Global Health (OVID), Web of Science, IBSS, IndMed and WHOLIS. We searched for studies that included police practices as an exposure for HIV or STI infection or HIV-related outcomes.

Results: Of the 137 peer-reviewed articles identified for full text review, 14 were included, representing sex workers' experiences with police across five settings. Arrest was the most commonly explored measure with between 6 and 45% of sex workers reporting having ever been arrested. Sexual coercion was observed between 3 and 37% of the time and police extortion between 12 and 28% across studies. Half the studies used a single measure to capture police behaviours. Studies predominantly focused on "extra-legal policing practices," with insufficient attention to the role of "legal enforcement activities". All studies found an association between police behaviours and HIV or STI infection, or a related risk behaviour.

Conclusions: The review points to a small body of evidence that confirms policing practices as an important structural HIV determinant for sex workers, but studies lack generalizability with respect to identifying those police behaviours most relevant to women's HIV risk environment.

Abstract  Full-text [free] access 

Editor’s notes: The paper reports on a systematic review, which explored how quantitative research to date has operationalized the measurement of law enforcement practices as a structural determinant of HIV for female (including transgender) sex workers. The authors reviewed 14 quantitative studies using policing practices as a micro-structural determinant for HIV risk among sex workers. They found substantial heterogeneity in both the police measures and the health outcomes considered by the different studies. Overall, the studies found that police measures were regularly reported by sex workers, with an average of 34% of sex workers experiencing at least one police measure. They found that arrest was the most commonly explored measure in the studies. Following this, sexual coercion and then police extortion were important.

The studies reported that these police measures were consistently, positively, associated with either HIV infection or STI symptoms or with inconsistent condom use. Having ever been arrested, sexual coercion, police extortion, and syringe confiscation was associated with an increased risk of acquiring an HIV infection or an STI. These measures, and displacement by the police, were also associated with inconsistent condom use. Intervening on interactions between sex workers and the police reduced HIV risk over the time of the programme.

The authors argue that these findings point to the potentially pivotal role that the police have as a structural determinant for HIV in vulnerable populations. However, they argue that nearly all the papers identified in this review fail to take account of the complexities of the risk environment in which law enforcement occurs. The authors thus suggest a need for better measures for legal and extra-legal enforcement practices as mechanisms through which sex workers’ HIV risk is mediated.

Africa, Asia, Europe, Latin America
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Research on intimate partner violence prevention - complex ethical issues

Ethical challenges of randomized violence intervention trials: examining the SHARE intervention in Rakai, Uganda.

Wagman JA, Paul A, Namatovu F, Ssekubugu R, Nalugoda F. Psychol Violence. 2016 Jul;6(3):442-451.

Objective: We identify complexities encountered, including unanticipated crossover between trial arms and inadequate 'standard of care' violence services, during a cluster randomized trial (CRT) of a community-level intimate partner violence (IPV) and HIV prevention intervention in Uganda.

Methods: Concepts in public health ethics - beneficence, social value of research, fairness, standard of care, and researcher responsibilities for post-trial benefits - are used to critically reflect on lessons learned and guide discussion on practical and ethical challenges of violence intervention CRTs.

Results: Existing ethical guidelines provide incomplete guidance for responding to unexpected crossover in CRTs providing IPV services. We struggled to balance duty of care with upholding trial integrity, and identifying and providing appropriate standard of care. While we ultimately offered short-term IPV services to controls, we faced additional challenges related to sustaining services beyond the 'short-term' and post-trial.

Conclusion: Studies evaluating community-level violence interventions, including those combined with HIV reduction strategies, are limited yet critical for developing evidence-based approaches for effectively preventing IPV. Although CRTs are a promising design, further guidance is needed to implement trials that avoid introducing tensions between validity of findings, researchers' responsibilities to protect participants, and equitable distribution of CRT benefits.

Abstract access

Editor’s notes: Data from 81 countries indicate that 30% of women aged 15 and above have experienced physical and/or sexual intimate partner violence in their lifetime. Settings with the highest intimate partner violence prevalence were found to be in sub-Saharan Africa, the region most affected by HIV.  Intimate partner violence is now widely accepted to be both a precursor to and sequelae of HIV infection. In response, a growing number of combination intimate partner violence and HIV prevention programmes have been implemented and systematically evaluated through randomised trials. The authors of this paper discuss some of the practical, ethical and safety challenges introduced by randomised trials on violence prevention, drawing on experience from a project in rural Uganda.

International guidelines have been established for the ethical conduct of biomedical research involving human subjects. The subject of violence against women and the method of randomised controlled trials are not easily resolved with these standard guidelines. In response, specialised recommendations for conducting safe and ethical population-based survey research on violence against women have been developed. These guidelines are an important development, but randomised trials to evaluate intimate partner violence prevention programmes face practical challenges in responding to common research ethics and safety considerations. These include: what to offer control communities in a trial investigating the optimal delivery approach for an activity likely to be effective in a setting with no standard of care. This needs to be done while maintaining the integrity of the study.

Drawing from their experience of the SHARE trial in the Rakai District in Uganda, the authors offer three reflections from lessons learned. (1) Ongoing need to formally update programmes that address multiple and overlapping vulnerabilities of individuals experiencing intimate partner violence and at risk of, or living with, HIV. (2) Cluster-randomised trials are a promising approach for programme evaluation but introduce numerous challenges with practical and ethical implications. (3) Given widespread underreporting of intimate partner violence, evaluation of violence programmes may have particularly high levels of unanticipated demand. The authors advocate for a framework of relevant considerations to be developed to guide researchers working on activities to reduce intimate partner violence. These guidelines should address potentially common challenges. They also encourage researchers to share field lessons arising from their studies in order to a) contribute to the development of this framework b) for revising and improving guidelines for the ethical conduct of intimate partner violence programmes in low resource settings.

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Increased adolescent testing

Increased adolescent HIV testing with a hybrid mobile strategy in Uganda and Kenya.

Kadede K, Ruel T, Kabami J, Ssemmondo E, Sang N, Kwarisiima D, Bukusi E, Cohen CR, Liegler T, Clark TD, Charlebois ED, Petersen ML, Kamya MR, Havlir DV, Chamie G, SEARCH team. AIDS. 2016 Jun 1. [Epub ahead of print]

Objective: We sought to increase adolescent HIV testing across rural communities in east Africa and identify predictors of undiagnosed HIV.

Design: Hybrid mobile testing.

Methods: We enumerated 116 326 adolescents (10-24 years) in 32 communities of Uganda and Kenya (SEARCH: NCT01864603): 98 694 (85%) reported stable (≥6 months of prior year) residence. In each community we performed hybrid testing: 2- week multi-disease community health campaign (CHC) that included HIV testing, followed by home-based testing of CHC non-participants. We measured adolescent HIV testing coverage and prevalence, and determined predictors of newly-diagnosed HIV among HIV+ adolescents using multivariable logistic regression.

Results: 86 421 (88%) stable adolescents tested for HIV; coverage was 86%, 90%, and 88% in early (10-14), mid (15-17) and late (18-24) adolescents, respectively. Self- reported prior testing was 9%, 26%, and 55% in early, mid and late adolescents tested, respectively. HIV prevalence among adolescents tested was 1.6% and 0.6% in Ugandan women and men, and 7.1% and 1.5% in Kenyan women and men, respectively. Prevalence increased in mid-adolescence for women, and late adolescence for men. Among HIV+ adolescents, 58% reported newly-diagnosed HIV. In multivariate analysis of HIV+ adolescents, predictors of newly-diagnosed HIV included male gender (OR = 1.97 [95%CI: 1.42-2.73]), Ugandan residence (OR = 2.63 [95%CI: 2.08-3.31]), and single status (OR = 1.62 [95%CI: 1.23-2.14] vs. married).

Conclusions: The SEARCH hybrid strategy tested 88% of stable adolescents for HIV, a substantial increase over the 28% reporting prior testing. The majority (57%) of HIV+ adolescents were new diagnoses. Mobile HIV testing for adults should be leveraged to reach adolescents for HIV treatment and prevention.

Abstract access 

Editor’s notes: Ending the AIDS epidemic requires much greater focus on adolescents, among whom HIV associated deaths is a leading cause of death in sub-Saharan Africa. Critical behaviours that are likely to impact on future health, such as risky sexual behaviour, often begin in adolescence. However, it is estimated that less than a third of adolescents in sub-Saharan Africa have been tested for HIV. In this paper, the authors report the impact of a hybrid community-based mobile testing approach to increase HIV testing among adolescents in rural communities in East Africa. This model, which does not rely on accessing schools or clinics, is very suitable for this age group, given the low rates of school attendance among female adolescents and the low use of clinic-based services by adolescents. A high rate of HIV testing was achieved, and testing for HIV in a multi-disease context may have enabled adolescents to access testing without fear of being stigmatised. However, uptake of testing is only the first stage in the HIV prevention and treatment cascade, and further data on the proportion of people testing positive who link to care and start treatment, and people testing negative who link to prevention services, are necessary. 

Kenya, Uganda
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Antiretroviral therapy: being reborn into uncertainty

What will become of me if they take this away? Zimbabwean women's perceptions of "free" ART.

Gona CM, McGee E, DeMarco R. J Assoc Nurses AIDS Care. 2016 May 13. pii: S1055-3290(16)30040-1. doi: 10.1016/j.jana.2016.05.001. [Epub ahead of print]

The evolution of antiretroviral therapies (ART) has redefined HIV infection from a life-threatening disease to a chronic manageable condition. Despite ART, HIV infection remains a serious health burden in Zimbabwe, particularly among women of reproductive age. In this interpretive phenomenology study, we interviewed 17 women with advanced HIV infection to uncover and understand their experiences of living with HIV infection in the ART era. Two themes (knowing the restorative power of ART and the heavy burden of being infected with HIV) reflected the women's experiences. ART brought physical and mental relief, but did not change the sobering reality of poverty or the challenges posed by the infective nature of HIV. The heavily donor-funded Zimbabwean ART program has been a success story, but there is uncertainty over its long-term sustainability. In resource-limited countries, clinicians and other stakeholders should continue to focus on HIV prevention as the cornerstone of HIV programming.

Abstract access

Editor’s notes: In Zimbabwe, as in much of sub-Saharan Africa, women are disproportionately affected by HIV infection. In 2013, women comprised 59% of adults living with HIV. Between 2007 and 2010, women accounted for 64% of people enrolled on ART in the country. Currently only 77% of women in clinical need of ART have access to it with most accessing it through a government and donor-funded ‘cost-free’ programme.  For women in Zimbabwe, living with HIV infection, normal life not only depends on the assurance of uninterrupted access to ART, but also the ability to get married and bear children.

The authors of this paper report on Zimbabwean women’s experiences of living with HIV infection while on ART. The study was nested within an ongoing clinical trial. Women were interviewed through in-depth, individual, face-to-face, open-ended interviews. 

The authors identify a number of important implications of the findings of this study. First, many women, in addition to concerns about their health, also had to contend with the effects of extreme poverty and gender inequality. For HIV treatment programmes to be successful, health care providers and policy makers should incorporate poverty reduction and gender equity components. Second, funding provisions should be put in place to ensure continued supplies of medications in order to reduce the reliance on external donor funding. Third, there is a need to clarify and strengthen policies regarding the continuation of treatment after the completion of a clinical trial to ensure participants’ continued access. Fourth, given the ability of ART to transform HIV into a chronic disease, reproductive health service provision should be prioritized to enable people living with HIV to have children if they wish. Further, and particularly in the light of these challenges, HIV prevention should be centralised as a focal point of HIV programming in order to reduce HIV incidence.

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Fishing, injection drug use and HIV risk

The association between psychosocial and structural-level stressors and HIV injection drug risk behavior among Malaysian fishermen: a cross-sectional study.

Michalopoulos LM, Jiwatram-Negron T, Choo MK, Kamarulzaman A, El-Bassel N. BMC Public Health. 2016 Jun 2;16(1):464. doi: 10.1186/s12889-016-3125-7.

Background: Malaysian fishermen have been identified as a key-affected HIV population with HIV rates 10 times higher than national rates. A number of studies have identified that psychosocial and structural-level stressors increase HIV injection drug risk behaviors. The purpose of this paper is to examine psychosocial and structural-level stressors of injection drug use and HIV injection drug risk behaviors among Malaysian fishermen.

Methods: The study employs a cross-sectional design using respondent driven sampling methods. The sample includes 406 fishermen from Pahang state, Malaysia. Using multivariate logistic regressions, we examined the relationship between individual (depression), social (adverse interactions with the police), and structural (poverty-related) stressors and injection drug use and risky injection drug use (e.g.., receptive and non-receptive needle sharing, frontloading and back-loading, or sharing drugs from a common container).

Results: Participants below the poverty line had significantly lower odds of injection drug use (OR 0.52, 95 % CI: 0.27-0.99, p = 0.047) and risky injection drug use behavior (OR 0.48, 95 % CI: 0.25-0.93, p = 0.030). In addition, participants with an arrest history had higher odds of injection use (OR 19.58, 95 % CI: 9.81-39.10, p < 0.001) and risky injection drug use (OR 16.25, 95 % CI: 4.73-55.85, p < 0.001). Participants with depression had significantly higher odds of engaging in risky injection drug use behavior (OR 3.26, 95 % 1.39-7.67, p = 0.007). Focusing on participants with a history of injection drug use, we found that participants with depression were significantly more likely to engage in risky drug use compared to participants below the depression cutoff (OR 3.45, 95 % CI: 1.23-9.66, p < 0.02).

Conclusions: Findings underscore the need to address psychosocial and structural-level stressors among Malaysian fishermen to reduce HIV injection drug risk behaviors.

Abstract  Full-text [free] access 

Editor’s notes: There is an increasing amount of research on high rates of HIV infection among people living in fishing communities in parts of Africa and Asia. There is also a lot of information on factors which put people in these fishing communities at risk of HIV infection. This paper is, however, the first study to look in detail at the association between risky injection drug use behaviours and HIV among fishermen. The authors of this fascinating and important paper provide a detailed analysis on the association between, what they call, individual, social and structural factors which contribute to risk. Interestingly, poorer fishermen were at less risk than fishermen who were better off, perhaps because poorer men could not afford the costs of injection drugs. However, the fear of the police, and the risk of arrest, resulted in injection practices which increased the risk of HIV infection. The authors note that the association between symptoms of depression and risky injection drug use may be an outcome of this behaviour rather than the cause. The authors highlight how fishermen using injection drugs to manage stress and risk in their lives, may compound the stress they face by this behaviour. The paper illustrates, very clearly, the complex relationship there often is between individual behaviours and the structural and social context. The authors provide very useful pointers for unpacking risk and HIV-infection in other similar populations. 

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Perceived stigma may lead to increased experienced stigma among people living with HIV

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

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

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

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

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

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

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

Abstract access

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

Northern America
United States of America
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Increased economic resources can reduce sexual vulnerability in young women

Economic resources and HIV preventive behaviors among school-enrolled young women in rural South Africa (HPTN 068).

Jennings L, Pettifor A, Hamilton E, Ritchwood TD, Xavier Gomez-Olive F, MacPhail C, Hughes J, Selin A, Kahn K. AIDS Behav. 2016 Jun 3. [Epub ahead of print]

Individual economic resources may have greater influence on school-enrolled young women's sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women's sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13-20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28-1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58-3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07-2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08-3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13-4.06), and discussing condom use (OR 1.99, 95 % CI 1.04-3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01-2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women's individual economic resources may complement future prevention initiatives.

Abstract access

Editor’s notes: Young women bear a disproportionate amount of the burden of the HIV epidemic in Africa. There are strong socioeconomic drivers of the epidemic, and gender inequalities and poverty combine to make adolescent girls and young women particularly vulnerable to HIV infection.  Economic programmes have been used in many countries to influence specific behaviours and to improve health outcomes. However, the evidence of their effectiveness in the context of HIV prevention is mixed. This study examined the association of individual economic resources with sexual behaviour in adolescent girls and young women. Although people with greater economic resources were more likely to have had sex, thus increasing their exposure to HIV infection, they were also more likely to engage in behaviours that were protective against HIV.  Not all economic resources had a positive effect on behaviour, underscoring the fact that sexual decision-making is complex and multi-faceted. The study population was unmarried, in school, and living with at least one parent or guardian, so the findings may not be generalisable to young women who are out of school or in less stable living arrangements. Improving the individual economic status of adolescent girls and young women may have a positive impact on HIV prevention behaviour. However, women’s choices may be constrained by social norms and entrenched inequalities. This study raises further questions about how economic resources may influence HIV risk in young women, but also in young men. 

South Africa
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Sex on the move

Exploring the relationship between population mobility and HIV risk: evidence from Tanzania.

Deane KD, Samwell Ngalya P, Boniface L, Bulugu G, Urassa M. Glob Public Health. 2016 May 27:1-16. [Epub ahead of print]

Migration and population mobility has long been regarded as an important structural driver of HIV. Following initial concerns regarding the spatial spread of the disease, mobile populations are viewed to engage in higher levels of risky sexual behaviours than non-mobile groups. However, beyond the case studies of mineworkers and truck drivers, the statistical evidence is inconclusive, suggesting that the relationship between mobility and risk is not well understood. This study investigated how engaging in specific livelihoods that involve mobility influences sexual behaviour and HIV risk. A qualitative research project, including focus groups and in-depth interviews with key mobile groups, was conducted in Northern Tanzania. The findings show that the patterns and conditions of moving related to the requirements of each different economic activity influence the nature of relationships that mobile groups have whilst away, how and where local sexual networks are accessed, and the practicalities of having sex. This has further implications for condom use. Risk behaviours are also shaped by local sexual norms related to transactional sex, emphasising that the roles of mobility and gender are interrelated, overlapping and difficult to disentangle.

Abstract access  

Editor’s notes: Case studies with truck drivers and mineworkers have clearly shown a relationship between migration, mobility and HIV risk in sub-Saharan Africa. It remains unclear to what extent findings from these case studies can be extrapolated across all mobile populations. Evidence from studies in other populations is inconclusive, inconsistent and in some cases contradictory. This, in part is due to the limitations of the statistical frameworks used which tend to reduce migration to an abstract individual variable and fail to recognise migration as a dynamic socio-economic phenomenon. These frameworks may also inadequately reflect the variability of migratory behaviour offering limited policy conclusions for addressing HIV risk arising from migration or population mobility.

This qualitative study was conducted in North-western Tanzania in a population in which 60% of men and 43% of women were classified as mobile. Data were collected through focus group discussions and individual interviews with both female and male farmers and maize traders.

The findings of this study suggest that patterns and conditions of moving can influence the nature of sexual relationships that mobile individuals have while away. The findings offer important insights for future, more nuanced statistical work. This would include considering why people move, where they go, patterns of movement, the specific economic activities in which they engage, and where they stay while they are away. The findings also highlight the importance of situating the risk behaviours of mobile individuals within the sexual norms and practices around sex and exchange, and particularly transactional sex. The authors note that being mobile may exacerbate gendered and economic inequalities making the relative influences of mobility and sexual norms difficult to disentangle. This further highlights the value of HIV prevention programmes being specifically tailored to the specific needs of mobile populations.

United Republic of Tanzania
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