Articles tagged as "Structural determinants and vulnerability"

Economic strengthening programmes for people living with HIV may increase their quality of life

The impact of social services interventions in developing countries: a review of the evidence of impact on clinical outcomes in people living with HIV.

Bateganya MH, Dong M, Oguntomilade J, Suraratdecha C. J Acquir Immune Defic Syndr. 2015 Apr 15;68 Suppl 3:S357-67. doi: 10.1097/QAI.0000000000000498.

Background: Social service interventions have been implemented in many countries to help people living with HIV (PLHIV) and household members cope with economic burden as a result of reduced earning or increased spending on health care. However, the evidence for specific interventions-economic strengthening and legal services-on key health outcomes has not been appraised.

Methods: We searched electronic databases from January 1995 to May 2014 and reviewed relevant literature from resource-limited settings on the impact of social service interventions on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission and their cost-effectiveness.

Results: Of 1685 citations, 8 articles reported the health impact of economic strengthening interventions among PLHIV in resource-limited settings. None reported on legal services. Six of the 8 studies were conducted in sub-Saharan Africa: 1 reported on all 5 outcomes and 2 reported on 4 and 2 outcomes, respectively. The remaining 5 reported on 1 outcome each. Seven studies reported on quality of life. Although all studies reported some association between economic strengthening interventions and HIV care outcomes, the quality of evidence was rated fair or poor because studies were of low research rigor (observational or qualitative), had small sample size, or had other limitations. The expected impact of economic strengthening interventions was rated as high for quality of life but uncertain for all the other outcomes.

Conclusions: Implementation of economic strengthening interventions is expected to have a high impact on the quality of life for PLHIV but uncertain impact on mortality, morbidity, retention in care, and HIV transmission. More rigorous research is needed to explore the impact of more targeted intervention components on health outcomes.

Abstract access 

Editor’s notes: To mitigate the impact of HIV on people living with HIV and their households, economic strengthening programmes and legal services have often been implemented. However, few have been rigorously evaluated in terms of their impact on HIV outcomes. This review of the literature reveals a limited and weak evidence base on the impact of such social services programmes for people living with HIV on mortality, morbidity, retention in HIV care, quality of life, and ongoing HIV transmission. It only identifies eight studies, all of them on economic strengthening activities, and most of them qualitative or observational in design. The authors conclude that the evidence suggests a high impact of such programmes on the quality of life for people living with HIV, which was consistently reported in the studies identified. Access to other confounding services, such as ART and broader community-based support, requires these findings to be interpreted with caution.     

The study clearly highlights the need for more rigorous impact and economic evaluations in this area. Indeed, the review did not identify any studies considering costs or cost-effectiveness. The authors also recommend more research into the feasibility and sustainability of these programmes, as well as greater focus of the implemented programmes on population groups in the greatest need.  

Africa, Asia, Latin America
  • share
0 comments.

Out of pocket spending on HIV care in India makes the poor even poorer

Consumption patterns and levels among households with HIV positive members and economic impoverishment due to medical spending in Pune city, India.

Sharma V, Krishnaswamy D, Mulay S. AIDS Care. 2015 Mar 4:1-5. [Epub ahead of print]

HIV infection poses a serious threat to the economy of a household. Out of pocket (OOP) health spending can be prohibitive and can drag households below poverty level. Based on the data collected from a cross-sectional survey of 401 households with HIV+ members in Pune city, India, this paper examines the consumption levels and patterns among households, and comments on the economic impoverishment resulting from OOP medical spending. Analysis reveals that households with HIV positive members spend a major portion of their monthly consumption expenditure on food items. Medical expenditure constitutes a large portion of their total consumption spending. Expenditure on children's education constitutes a minor proportion of total monthly spending. A high proportion of medical expenditure has a bearing on the economic condition of households with HIV positive members. Poverty increases by 20% among the studied HIV households when OOP health spending is adjusted. It increases 18% among male-headed households and 26% among female-headed households. The results reiterate the need of greater support from the government in terms of accessibility and affordability of health care to save households with HIV positive members from economic catastrophe.

Abstract access 

Editor’s notes: This paper describes expenditure patterns for households with one or more people living with HIV. The authors find that medical expenditure within a household with a member living with HIV is relatively high, some 9.6% of total expenditure. Overall, households were economically vulnerable, with health-associated spending often pushing people below the poverty line. This type of research is especially timely in the context of increasing interest in reducing out of pocket expenditure. Further research around the poverty effects of illness is critical to inform policies as universal access to health care becomes a greater international priority.  

Asia
India
  • share
0 comments.

The need for improved services for minors who sell sex in West Africa

Structural determinants of health among women who started selling sex as minors in Burkina Faso.

Grosso AL, Ketende S, Dam K, Papworth E, Ouedraogo HG, Ky-Zerbo O, Baral S. J Acquir Immune Defic Syndr. 2015 Mar 1;68 Suppl 2:S162-70. doi: 10.1097/QAI.0000000000000447.

Objectives: To explore the prevalence of and factors associated with initiation of selling sex as a minor.

Design: Data were drawn from cross-sectional studies of adult female sex workers (FSW) recruited through respondent-driven sampling in Ouagadougou and Bobo-Dioulasso, Burkina Faso.

Methods: FSW completed a questionnaire that included a retrospective question regarding the age at which they started selling sex. Separate multivariate logistic regression analyses were conducted for each city to examine associations with initiation of selling sex as a minor (<18 year old), controlling for current age.

Results: Of study participants, 27.8% (194/698) reported selling sex as a minor, ranging from 24.4% (85/349) in Bobo-Dioulasso to 31.2% (85/349) in Ouagadougou. In Ouagadougou, early initiates were more than twice as likely to report someone ever forced them to have sex [age-adjusted odds ratio (aaOR): 2.54, 95% confidence interval (CI): 1.53 to 4.23]. In Bobo-Dioulasso, those who started as minors were more likely to report someone ever tortured them (aaOR: 2.29, 95% CI: 1.28 to 4.10). In both cities, early initiates were more likely to not use a condom with a client if offered more money (Ouagadougou aaOR: 2.34, 95% CI: 1.23 to 4.47; Bobo-Dioulasso aaOR: 2.37, 95% CI: 1.29 to 4.36). In Ouagadougou, women who had started selling sex at a young age were half as likely to have been tested for HIV more than once ever (aaOR: 0.50, 95% CI: 0.26 to 0.94). In Bobo-Dioulasso, early initiates were less likely to attend HIV-related talks or meetings (aaOR: 0.56, 95% CI: 0.33 to 0.97).

Conclusions: A substantial proportion of FSW in Burkina Faso started selling sex as minors. The findings show that there are heightened vulnerabilities associated with selling sex below age 18 years, including physical and sexual violence, client-related barriers to condom use, and lower access to HIV-related services.

Abstract access 

Editor’s notes: Young girls in sub-Saharan Africa are at increased risk of acquiring HIV compared with their male peers. Studies have identified both individual-level and structural-level risks for HIV infection among young girls, including inconsistent condom use and violence. Female sex workers who start selling sex as minors are particularly vulnerable to these risks. In West and central Africa, HIV infection is concentrated among key populations, such as female sex workers, with pooled HIV prevalence estimated to be 34.9%. Despite this, there have been relatively few studies of girls who sell sex in sub-Saharan Africa compared to multiple studies that have been conducted in Asia and the Americas. This is one of the first studies comparing early and later initiation of selling sex in West Africa. This study, using data from cross-sectional studies, investigated the structural determinants of health associated with the start of selling sex as a minor among female sex workers in Burkina Faso. The investigators found that almost a third of female sex workers had started selling sex as minors, and early initiation of selling sex was associated with a range of behavioural risk factors. In addition these women were more likely to experience social and structural vulnerabilities including limited access to health services, and violence. The study highlights the need to provide HIV services for minors who sell sex in sub-Saharan Africa, and to prevent sexual exploitation of children.

Africa
Burkina Faso
  • share
0 comments.

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
  • share
0 comments.

Does having an older male partner actually protect women over 30 in KwaZulu-Natal?

Partner age-disparity and HIV incidence risk for older women in rural South Africa.

Harling G, Newell ML, Tanser F, Barnighausen T. AIDS Behav. 2015 Feb 11. [Epub ahead of print]

While sexual partner age disparity is frequently considered as a potential risk factor for HIV among young women in Africa, no research has addressed this question among older women. Our aim was thus to determine whether sex partner age disparity was associated with subsequent HIV acquisition in women over 30 years of age. To achieve this aim we conducted a quantitative analysis of a population-based, open cohort of women in rural KwaZulu-Natal, South Africa (n = 1737) using Cox proportional hazards models. As partner age rose, HIV acquisition risk fell significantly: compared to a same-aged partner, a 5-year older partner was associated with a one-third reduction [hazard ratio (HR) 0.63, 95 % CI 0.52-0.76] and a 10-year older partner with a one-half reduction (HR 0.48, 95 % CI 0.35-0.67) in acquisition risk. This result was neither confounded nor effect-modified by women's age or socio-demographic factors. These findings suggest that existing HIV risk-reduction campaigns warning young women about partnering with older men may be inappropriate for older women. HIV prevention strategies interventions specifically tailored to older women are needed.

Abstract access

Editor’s notes: The effect of partner age disparity is important for the dynamics of HIV transmission. This is because of the potential of transmission across generations, and also that it may reflect power imbalances with associated vulnerabilities and risks. This study is the first to assess HIV risk and partner age disparity in women between the ages of 30 and 50 years. As might be expected, the associations are different to those generally found in young women where having an older partner typically increases HIV risk. In this study, having a partner five years older reduces HIV risk by one third, and having a partner 10 years older reduces HIV risk by half. This is not surprising for several reasons, including that HIV prevalence decreases with older age. But it highlights the need for HIV prevention campaigns that advocate for women to avoid older men, to be nuanced by the age of the woman.  However, it is also notable that in this population, a previous paper showed no evidence of an association of partner age disparity and HIV risk for women aged 15-29. The results illustrate the need to continue to broaden and improve HIV prevention programming and to tailor prevention messages for different age groups, as the traditional ‘risky behaviours’ for young women may not be appropriate for older ages.

Africa
South Africa
  • share
0 comments.

Don’t ask, don’t tell: concealment as a stigma management strategy in India

'I am doing fine only because I have not told anyone': the necessity of concealment in the lives of people living with HIV in India.

George MS, Lambert H. Cult Health Sex. 2015 Feb 23:1-14. [Epub ahead of print]

In HIV prevention and care programmes, disclosure of status by HIV-positive individuals is generally encouraged to contain the infection and provide adequate support to the person concerned. Lack of disclosure is generally framed as a barrier to preventive behaviours and accessing support. The assumption that disclosure is beneficial is also reflected in studies that aim to identify determinants of disclosure and recommend individual-level measures to promote disclosure. However, in contexts where HIV infection is stigmatised and there is fear of rejection and discrimination among those living with HIV, concealment of status becomes a way to try and regain as much as possible the life that was disrupted by the discovery of HIV infection. In this study of HIV-positive women and children in India, concealment was considered essential by individuals and families of those living with HIV to re-establish and maintain their normal lives in an environment where stigma and discrimination were prevalent. This paper describes why women and care givers of children felt the need to conceal HIV status, the various ways in which people tried to do so and the implications for treatment of people living with HIV. We found that while women were generally willing to disclose their status to their husband or partner, they were very keen to conceal their status from all others, including family members. Parents and carers with an HIV-positive child were not willing to disclose this status to the child or to others. Understanding the different rationales for concealment would help policy makers and programme managers to develop more appropriate care management strategies and train care providers to assist clients in accessing care and support without disrupting their lives.

Abstract access 

Editor’s notes: This paper provides a powerful illustration of the persistence of stigma in the lives of many people living with HIV in India. Using data collected in 2012, the authors illustrate how prejudice and discrimination shape the lives of the women and children included in this study. While access to antiretroviral therapy (ART) provided a way for participants to regain and maintain what is described as ‘normal life’, that same treatment could result in unintended disclosure. Participants spoke of the fear of being seen carrying ART, since illustrations of the pills were widely available at clinics. They described the challenges of disclosing to their children as well as other relatives. Disclosure to wider social networks posed a reputational threat because of the association of HIV with moral laxity. All these are challenges that many people face in other settings too, providing further evidence of the persistence of HIV-associated stigma. The authors also illustrate the unintended consequences of well-meaning policies. One striking illustration came from a participant who was using a free travel pass, available to people living with HIV to collect their treatment. The pass included the word ‘AIDS’ and a ticket collector ridiculed the woman and her husband in front of other passengers because of this evidence of infection. The authors make the point that encouraging disclosure may overlook the importance of concealment as a way to cope with stigma. 

Asia
India
  • share
0 comments.

The impact of homophobia and criminalisation on MSM HIV vulnerability worldwide

Sexual stigma, criminalization, investment, and access to HIV services among men who have sex with men worldwide.

Arreola S, Santos GM, Beck J, Sundararaj M, Wilson PA, Hebert P, Makofane K, Do TD, Ayala G. AIDS Behav. 2015 Feb;19(2):227-34. doi: 10.1007/s10461-014-0869-x.

Globally, HIV disproportionately affects men who have sex with men (MSM). This study explored associations between access to HIV services and (1) individual-level perceived sexual stigma; (2) country-level criminalization of homosexuality; and (3) country-level investment in HIV services for MSM. 3340 MSM completed an online survey assessing access to HIV services. MSM from over 115 countries were categorized according to criminalization of homosexuality policy and investment in HIV services targeting MSM. Lower access to condoms, lubricants, and HIV testing were each associated with greater perceived sexual stigma, existence of homosexuality criminalization policies, and less investment in HIV services. Lower access to HIV treatment was associated with greater perceived sexual stigma and criminalization. Criminalization of homosexuality and low investment in HIV services were both associated with greater perceived sexual stigma. Efforts to prevent and treat HIV among MSM should be coupled with structural interventions to reduce stigma, overturn homosexuality criminalization policies, and increase investment in MSM-specific HIV services.

Abstract access 

Editor’s notes: Homosexuality is still illegal in 39% of the 193 UN recognised countries. This criminalisation likely increases HIV vulnerability among gay men and other men who have sex with men. In this study, 3340 gay men and other men who have sex with men from more than 115 countries completed an online survey about their perceptions of homophobia and their ease of accessing basic HIV prevention services. The authors conducted an ecological analysis to examine the relationship between the uptake of HIV services among gay men and other men who have sex with men. The authors looked at structural factors at the individual level which included their perceptions of homophobia within the society in which they live and at the country level including criminalising policies. More than 50% of respondents reported difficulty in accessing HIV services including condoms, lubricants, HIV testing services and antiretroviral therapy (ART). Perceived homophobia, criminalization of homosexual behaviour, and low country investment in HIV services were each associated with reduced access to condoms, lubricants, HIV testing services and ART. Improving access to HIV services for gay men and other men who have sex with men is urgently required as they carry a disproportionate burden of HIV in low and middle income countries. This study adds to a body of evidence which suggests that addressing structural barriers such as the criminalisation of homosexuality and sexual stigma (homophobia) will be necessary to reduce HIV vulnerability among gay men and other men who have sex with men, globally.

  • share
0 comments.

Incentives for orphans to stay in school: a structural programme for HIV prevention in Zimbabwe

The impact of school subsidies on HIV-related outcomes among adolescent female orphans.

Hallfors DD, Cho H, Rusakaniko S, Mapfumo J, Iritani B, Zhang L, Luseno W, Miller T. J Adolesc Health. 2015 Jan;56(1):79-84. doi: 10.1016/j.jadohealth.2014.09.004.

Purpose: We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years.

Methods: Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status.

Results: The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group.

Conclusions: Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.

Abstract access

Editor’s notes: Structural programmes for HIV prevention potentially offer a means to mitigate the risk factors which are thought to drive the substantially higher rates of HIV observed among adolescent women in low-income settings. In Zimbabwe, female orphans in the programme arm of this randomized control trial were offered a package of school support. This included payment of their school fees. There was low power to assess differences in HIV or HSV-2 prevalence by arm, but there were promising impacts on several important mediating factors for HIV infection. These included sexual debut, marriage, school drop-out, and socioeconomic status. The long follow-up period of five years and the high rate of retention in the study, 88%, are major strengths of this study. The study joins a limited evidence base on structural programmes for adolescent women in sub-Saharan Africa. Future research must re-consider the pathways by which structural determinants of HIV infection operate.

Africa
Zimbabwe
  • share
0 comments.

Savings-led microfinance programme leads to lower sexual risk among sex workers in Mongolia

Efficacy of a savings-led microfinance intervention to reduce sexual risk for HIV among women engaged in sex work: a randomized clinical trial.

Witte SS, Aira T, Tsai L, Riedel M, Offringa R, Chang M, El-Bassel N, Ssewamala F. Am J Public Health. 2015 Mar;105(3):e95-e102. doi: 10.2105/AJPH.2014.302291. Epub 2015 Jan 20.

Objectives: We tested whether a structural intervention combining savings-led microfinance and HIV prevention components would achieve enhanced reductions in sexual risk among women engaging in street-based sex work in Ulaanbaatar, Mongolia, compared with an HIV prevention intervention alone.

Methods: Between November 2011 and August 2012, we randomized 107 eligible women who completed baseline assessments to either a 4-session HIV sexual risk reduction intervention (HIVSRR) alone (n = 50) or a 34-session HIVSRR plus a savings-led microfinance intervention (n = 57). At 3- and 6-month follow-up assessments, participants reported unprotected acts of vaginal intercourse with paying partners and number of paying partners with whom they engaged in sexual intercourse in the previous 90 days. Using Poisson and zero-inflated Poisson model regressions, we examined the effects of assignment to treatment versus control condition on outcomes.

Results: At 6-month follow-up, the HIVSRR plus microfinance participants reported significantly fewer paying sexual partners and were more likely to report zero unprotected vaginal sex acts with paying sexual partners.

Conclusions: Findings advance the HIV prevention repertoire for women, demonstrating that risk reduction may be achieved through a structural intervention that relies on asset building, including savings, and alternatives to income from sex work.

Abstract access

Editor’s notes: This study on sexual risk among sex workers in Ulaanbaatar, Mongolia, contributes to evidence that economic empowerment reduces HIV risk. Mongolia has a low prevalence of HIV. But it is considered highly vulnerable to the spread of HIV. This suggests that such programmes should be implemented to prevent concentrated epidemics becoming generalised epidemics. The authors acknowledge that while microfinance might be economically empowering it may represent “saving down”, which can keep women in debt and in a cycle of poverty and a reliance on sex work. The trial tested whether increasing financial literacy, business development knowledge and skills and personal savings would lead to more significant reductions in sexual risk behaviours than a sexual risk reduction programme alone. Groups of sex workers were randomised to receive either a four session HIV sexual risk reduction programme (HIVSRR) or HIVSRR plus a savings-led microfinance programme. The HIVSRR alone involved the delivery of two sessions per week for two weeks and focused on skills to develop self-efficacy for risk reduction. The HIVSRR plus savings-led microfinance programme involved the four sessions on self-efficacy for risk reduction, followed by 12 financial literacy sessions three times a week and then 12 sessions of business development training three times a week. The activities were tested at three months and six months to explore the short time impact on sexual risk. The authors found that women who received the HIVSSRR plus savings-led microfinance programme reported greater reductions in number of paying sexual partners and fewer sexual partners at six months follow up. These women were also more likely to report no unprotected vaginal sex acts at six months follow up. This study is important in illustrating that as a structural programme, the provision of microfinance is more effective if women are provided with skills to manage finances and to save money instead of ending up in a cycle of debt repayment. This has important implications for other microfinance programmes, such as programmes to reduce gender-based violence.

Asia
Mongolia
  • share
0 comments.

More research is needed for understanding predictors of internalized stigma among people living with HIV

Predictors of internalised HIV-related stigma: a systematic review of studies in sub-Saharan Africa.

Pantelic M, Shenderovich Y, Cluver L, Boyes M. Health Psychol Rev. 2015 Jan 3:1-45. [Epub ahead of print]

Objective: This systematic review aims to synthesize evidence on predictors of internalised HIV stigma amongst people living with HIV in sub-Saharan Africa.

Method: PRISMA guidelines were used. Studies were identified through electronic databases, grey literature, reference harvesting and contacts with key researchers. Quality of findings was assessed through an adapted version of the Cambridge Quality Checklists.

Results: A total of 590 potentially relevant titles were identified. Seventeen peer-reviewed articles and one draft book chapter were included. Studies investigated socio-demographic, HIV-related, intra-personal and inter-personal correlates of internalised stigma. Eleven articles used cross-sectional data, six articles used prospective cohort data and one used both prospective cohort and cross-sectional data to assess correlates of internalised stigma. Poor HIV-related health weakly predicted increases in internalized HIV stigma in three longitudinal studies. Lower depression scores and improvements in overall mental health predicted reductions in internalized HIV stigma in two longitudinal studies, with moderate and weak effects respectively. No other consistent predictors were found.

Conclusion: Studies utilizing analysis of change and accounting for confounding factors are necessary to guide policy and programming but are scarce. High-risk populations, other stigma markers that might layer upon internalised stigma, and structural drivers of internalised stigma need to be examined.

Abstract access 

Editor’s notes: Internalized stigma can act as a barrier to HIV prevention and treatment. It can occur when a person living with HIV endorses negative attitudes associated with HIV and accepts these attitudes as applicable to themselves. Few stigma reduction programmes exist for people living with HIV. However, two recent studies have illustrated that internalized stigma reduction may be feasible through programmes targeting individual level factors. This paper systematically reviewed the evidence on predictors of internalized stigma among people living with HIV. The review included 18 papers looking at 13 unique studies in South Africa, Lesotho, Malawi, United Republic of Tanzania, Swaziland, Mozambique, Uganda, Kenya and Burkina Faso. All included studies were observational including prospective cohort and cross-sectional study designs. In all studies, participants were recruited through health facilities. Most included studies did not report on sampling methods.

All included studies defined internalized stigma as a negative self-perception due to HIV status and the resultant feelings of shame, difficulties around disclosure and self-exclusion. Only one study looked at the effect of antiretroviral therapy (ART) use on internalized stigma and found no evidence of an association. There was weak evidence across three studies that improved physical health (measured as improved physical functioning and fewer HIV-associated symptoms) lead to reductions in internalized HIV stigma. Two studies found some evidence that lower depression scores and improvements in overall mental health predicted reductions in internalized HIV stigma. There were inconsistent findings on whether time on ART had any association with internalized stigma. No other associations with socio-demographic or interpersonal factors were found. This is a field of new and emerging research and no implications for practice can be drawn given the inconsistent findings across studies. The cross-sectional nature of most of the included studies means that it is not possible to assess long-term associations. Further research is needed to understand the factors associated with internalized stigma and how these might change over time. Future research should use rigorous study methods and should focus on key populations, HIV transmission, and structural drivers of HIV.

Africa
  • share
0 comments.