Articles tagged as "Eliminate stigma and discrimination"

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.

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

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

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

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

Abstract access

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

Latin America
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Potential for psychological programmes for mental disorders among people living with HIV: further studies necessary in sub-Saharan Africa

Psychological interventions for common mental disorders for people living with HIV in low- and middle-income countries: systematic review.

Chibanda D, Cowan FM, Healy JL, Abas M, Lund C. Trop Med Int Health. 2015 Mar 7. doi: 10.1111/tmi.12500. [Epub ahead of print]

Objective: To assess the effectiveness of structured psychological interventions against common mental disorders (CMD) in people living with HIV infection (PLWH), in low- and middle-income countries (LMIC).

Methods: Systematic review of psychological interventions for CMD from LMIC for PLWH, with two-stage screening carried out independently by 2 authors.

Results: Of 190 studies, 5 met inclusion criteria. These were randomised-controlled trials based on the principles of cognitive behaviour therapy (CBT) and were effective in reducing CMD symptoms in PLWH. Follow-up of study participants ranged from 6 weeks to 12 months with multiple tools utilised to measure the primary outcome. Four studies showed a high risk of bias, while 1 study from Iran met low risk of bias in all 6 domains of the Cochrane risk of bias tool and all 22 items of the CONSORT instrument.

Conclusion: There is a need for more robust and adequately powered studies to further explore CBT-based interventions in PLWH. Future studies should report on components of the psychological interventions, fidelity measurement and training, including supervision of delivering agents, particularly where lay health workers are the delivering agent.

Abstract   Full-text [free] access

Editor’s notes: Common mental disorders (CMD) including depression and anxiety, are highly prevalent among people living with HIV and contribute to poor HIV outcomes, including treatment failure. However, the lack of mental health professionals in many low- and middle-income countries means that lay health workers can play an important role in treating CMD. This has been well-documented from non-HIV settings, but not among people living with HIV. This systematic review found that few studies have rigorously evaluated the effectiveness of psychological programmes for CMD among people living with HIV (and only one from sub-Saharan Africa), but all of these reported benefits in the activity arm compared to the control arm. This suggests that further, large, well-designed trials are necessary to evaluate such activities especially in countries most severely affected by HIV in southern and eastern Africa. Key points raised by this review include the need for locally validated tools to assess mental health outcomes in future trials. The importance of formative work to develop and finalise the programme for the trial setting, including local stakeholders, systems for assessing the fidelity of the activity, and a referral or supervision plan, is ever more emphasized.  

Africa, Asia
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Barriers and facilitators of safer sexual behaviour for people living with HIV on ART

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

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

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

Abstract   Full-text [free] access

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

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

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

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

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

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

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

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

Abstract access 

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

Burkina Faso, Togo
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People who inject drugs and the effects of stigma on HIV treatment

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

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

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

Abstract access 

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

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

Estonia, Russian Federation
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Expectations and experiences of disclosing HIV status to sexual partners in Ghana

The 'fears' of disclosing HIV status to sexual partners: a mixed methods study in a counseling setting in Ghana.  

Obiri-Yeboah D, Amoako-Sakyi D, Baidoo I, Adu-Oppong A, Rheinlander T. AIDS Behav. 2015 Feb 26. [Epub ahead of print]

Encouraging disclosure within a trusting and supportive environment is imperative in dealing with HIV/AIDS related stigma. However, disclosure rates and the factors that influence it are vaguely understood in African societies. This study aimed at determining the disclosure rate and factors that influence disclosure in Cape Coast, Ghana. In-depth interviews of 15 peer educators and a survey of 510 PLHIV were used in a mixed methods study design. Majority of the study participants (78.6 %) had disclosed their HIV positive status to their sexual partners. Although peer educators in this study portrayed the overall outcome of disclosure to be negative, 84.0 % of disclosers were accepted by their partners without negative consequences after disclosure. This study suggests that the existing support services ill prepares newly diagnosed HIV positive clients and hampers disclosure initiatives. Providing comprehensive support services and re-training peer educators may be crucial in creating a safe disclosure environment in Ghana.

Abstract access

Editor’s notes: This mixed methods study explores the important issue of disclosure to sexual partners. Supporting increased rates of disclosure to partners is crucial for effective prevention efforts. But it may also be valuable in influencing the support that people living with HIV can receive from their sexual partner to manage their condition. This is pertinent because other research has illustrated that keeping their status a secret from partners and household members can impede adherence and sustained access to care. The initial data analysis of the 15 in-depth interviews with peer educators was used to inform the design of the questionnaire which was then completed by 510 people living with HIV in Cape Coast, Ghana. The findings from the formative qualitative research are also used to explain some of the subsequent quantitative findings.  

There are two particularly striking findings reported in the paper. The first is that among individuals who have disclosed their status, a significant majority, some 82%, did so within the first week of having been diagnosed. This suggests that there is a crucial, but short, window in which individuals may be more willing to disclose to partners. This is important for programme design and ensuring that pre- and post-test counselling includes discussion and support to disclose to partners. The second key finding is that while the survey data illustrates that the experience of disclosers was predominately positive, the 15 peer educators captured in the qualitative study portrayed a far more negative expectation about the risks involved in disclosure to partners. The time that had passed since individuals were diagnosed was not presented for either the quantitative or qualitative samples. Given the changing meaning of HIV within the context of antiretroviral therapy, the time since participants’ diagnosis and subsequent disclosure to partners may be an important factor in shaping individuals’ experiences and thus their expectations of the impact of disclosure. The evidence presented in this paper illustrates the importance not only of examining the experiences and expectations of disclosure by people living with HIV, but also in considering what may be influencing their expectations. The peer educator’s role may limit, as well as support, peoples’ readiness to disclose to partners. 

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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. 

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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.

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Keeping adolescent girls in HIV prevention clinical trials: a focus on the effects of domestic violence

Domestic violence among adolescents in HIV prevention research in Tanzania: participant experiences and measurement issues.

Baumgartner JN, Kaaya S, Karungula H, Kaale A, Headley J, Tolley E. Matern Child Health J. 2015 Jan;19(1):33-9. doi: 10.1007/s10995-014-1492-1.

Under-representation of female adolescents in HIV clinical trials may inhibit their access to future prevention technologies. Domestic violence, broadly defined as violence perpetrated by intimate partners and/or family members, may affect trial participation. This study describes violence in the lives of adolescents and young women in Tanzania, explores use of the Women's Experience with Battering (WEB) Scale to measure battering, and examines the associations between battering and socio-demographic and HIV risk factors. Community formative research (CFR) and a mock clinical trial (MCT) were conducted to examine the challenges of recruiting younger (15-17) versus older (18-21) participants into HIV prevention trials. The CFR included qualitative interviews with 23 participants and there were 135 MCT participants. The WEB was administered in both the CFR and MCT. Nineteen CFR participants experienced physical and/or sexual violence and 17 % scored positive for battering. All married participants reported partner-related domestic violence, and half scored positive for battering. Many believed beatings were normal. None of the single participants scored positive on battering, but one-third reported abuse by relatives. Among MCT participants, 15 % scored positive for battering; most perpetrators were relatives. Younger participants were more likely to report battering. Adolescents experienced high rates of domestic violence and the WEB captured battering from both partners and relatives. The level of familial violence was unexpected and has implications for parental roles in study recruitment. Addressing adolescent abuse in HIV prevention trials and in the general population should be a public health priority.

Abstract access

Editor’s notes: Despite their heightened HIV vulnerability, adolescent girls are under-represented in clinical trials on HIV prevention technologies. Domestic violence is a known HIV risk factor for adolescent girls and the authors posit that it may also be a barrier to their participation in clinical trials. This lack of participation may in turn inhibit their access to future prevention technologies. This paper contributes both methodological insights about the measures that can be applied in low-income settings to screen for domestic violence and substantive evidence about the high rates of familial as well as partner associated violence and battering among this group.

The paper draws on data from a larger study conducted in the United Republic of Tanzania which examined recruitment and retention of adolescent girls, aged 15-21 years, in HIV prevention trials. The paper examines the prevalence and type of domestic violence among this group and the capacity of the Women’s Experience with Battering (WEB) scale to measure this. Although the WEB scale has not been used in low income countries before, the authors report that it may have considerable value in identifying exposure to domestic violence and battering among trial participants. Certain adaptations may be necessary, to identify women who are subject to violence and battering but do no report being afraid of the perpetrator. The qualitative study component suggests that this may reflect how beatings are considered a normal aspect of intimate and familial relations. Although this assessment tool is likely to be able to inform trial retention initiatives, the adolescent girls need to be able to participate in these trials. So the use of the scale appears to be limited in its contribution to improving initial recruitment into trials.

The levels of familial battering were higher than expected. This is likely to have implications for parental roles in research and contributes to the ethical concerns of relying on parental consent in HIV prevention trials rather than pursuing the route of autonomy in consenting. This is illustrated by the study itself requiring parental consent for girls aged 15 years.  This paper’s focus was on how to address the under-representation of adolescent girls in HIV prevention trials. Further, it provides valuable evidence on the high rates of exposure of adolescent girls to domestic violence from partners and their relatives. This evidence contributes to the call for greater attention to adolescent domestic violence in global health. 

United Republic of Tanzania
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