Articles tagged as "Eliminate stigma and discrimination"

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
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Feelings of regret after HIV status disclosure: prevalence, trends, and determinants

Was it a mistake to tell others that you are infected with HIV?: factors associated with regret following HIV disclosure among people living with HIV in five countries (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). Results from a community-based research.

Henry E, Bernier A, Lazar F, Matamba G, Loukid M, Bonifaz C, Diop S, Otis J, Préau M; The Partages study group. AIDS Behav. 2014 Dec 23. [Epub ahead of print]

This study examined regret following HIV serostatus disclosure and associated factors in under-investigated contexts (Mali, Morocco, Democratic Republic of the Congo, Ecuador and Romania). A community-based cross-sectional study was implemented by a mixed consortium [researchers/community-based organizations (CBO)]. Trained CBO members interviewed 1500 PLHIV in contact with CBOs using a 125-item questionnaire. A weighted multivariate logistic regression was performed. Among the 1212 participants included in the analysis, 290 (23.9 %) declared that disclosure was a mistake. Female gender, percentage of PLHIV's network knowing about one's seropositivity from a third party, having suffered rejection after disclosure, having suffered HIV-based discrimination at work, perceived seriousness of infection score, daily loneliness, property index and self-esteem score were independently associated with regret. Discrimination, as well as individual characteristics and skills may affect the disclosure experience. Interventions aiming at improving PLHIV skills and reducing their social isolation may facilitate the disclosure process and avoid negative consequences.

Abstract access 

Editor’s notes: Anticipated and perceived consequences of disclosing one’s HIV status are recognized as important drivers for HIV disclosure. This community-based study looked at the experience of disclosing one’s HIV status, and the emotions that were associated with disclosure. The study was nested within a larger cross-sectional research project. 1500 people living with HIV (PLHIV) from Ecuador, the Democratic Republic of the Congo (DRC), Mali, Romania, and Morocco were included in the study. Respondents were asked ‘Was it a mistake to tell others that you are infected with HIV?’ and to answer either ‘yes’ or ‘no.' Participants also responded to questions about the process of disclosure. Among people that had disclosed their status, some 23.9% said that it was a mistake to do so. Almost 40% of participants said that a person in their network learned about their status from a third party. More than 17% of participants responded that they faced rejection and eight percent of participants suffered discrimination at work following disclosure. But this varied greatly across countries. Factors associated with feeling regret after disclosing one’s status included being a female, perceived seriousness of HIV infection, and feeling lonely every day. This study highlights the fact that status disclosure can be emotional and stressful for people living with HIV. This suggests that people living with HIV must weigh the costs and benefits of disclosure before doing so and programmes that empower them to make informed decisions about disclosure may be beneficial. 

Africa, Europe, Latin America
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Does ‘treat’ always follow ‘test’? Why some people do not want HIV treatment

Understanding treatment refusal among adults presenting for HIV-testing in Soweto, South Africa: a qualitative study.

Katz IT, Dietrich J, Tshabalala G, Essien T, Rough K, Wright AA, Bangsberg DR, Gray GE, Ware NC. AIDS Behav. 2014 Oct 11. [Epub ahead of print]

HIV treatment initiatives have focused on increasing access to antiretroviral therapy (ART). There is growing evidence, however, that treatment availability alone is insufficient to stop the epidemic. In South Africa, only one third of individuals living with HIV are actually on treatment. Treatment refusal has been identified as a phenomenon among people who are asymptomatic, however, factors driving refusal remain poorly understood. We interviewed 50 purposively sampled participants who presented for voluntary counseling and testing in Soweto to elicit a broad range of detailed perspectives on ART refusal. We then integrated our core findings into an explanatory framework. Participants described feeling "too healthy" to start treatment, despite often having a diagnosis of AIDS. This subjective view of wellness was framed within the context of treatment being reserved for the sick. Taking ART could also lead to unintended disclosure and social isolation. These data provide a novel explanatory model of treatment refusal, recognizing perceived risks and social costs incurred when disclosing one's status through treatment initiation. Our findings suggest that improving engagement in care for people living with HIV in South Africa will require optimizing social integration and connectivity for those who test positive.

Abstract access 

Editor’s notes: In many countries there is increasing pressure to bring more people living with HIV into treatment, by raising the CD4+ threshold for treatment access and advocating ‘test and treat’ approaches for key populations. While concerns are often raised about whether there are adequate supplies of drugs and the capacity of health systems to cope, the willingness of the key population to come on to treatment is seldom questioned. Why shouldn’t people want life-saving drugs? This paper is, therefore, extremely timely. The authors describe clearly and convincingly the reasons why men and women in South Africa may defer or refuse to access treatment.  People may hold the belief that treatment is only for the sick, and therefore someone who shows no signs of infection does not need pills. Some express concerns over the stigma associated with an HIV positive status while others profess their confidence in spirituality and faith. Antiretroviral therapy as a signifier of AIDS and approaching death is viewed as negative, not a life saver. Understanding the beliefs that stand in the way of treatment access is essential. Providing adequate support to help people come forward for treatment, and be sustained on treatment, is also important. The authors of this important paper document the barriers to engagement in care. Barriers which are not disappearing. We need to understand why some men and women do not want treatment and, as the authors note, test programmes that can ‘optimise engagement in care’.

Africa
South Africa
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The challenge of living with HIV and being a ‘real man’ – the intersection of stigma and masculinity

Intersectionality of HIV stigma and masculinity in eastern Uganda: implications for involving men in HIV programmes.

Mburu G, Ram M, Siu G, Bitira D, Skovdal M, Holland P. BMC Public Health. 2014 Oct 11;14:1061. doi: 10.1186/1471-2458-14-1061.

Background: Stigma is a determinant of social and health inequalities. In addition, some notions of masculinity can disadvantage men in terms of health outcomes. However, few studies have explored the extent to which these two axes of social inequality intersect to influence men's health outcomes. This paper investigates the intersection of HIV stigma and masculinity, and its perceived impact on men's participation in and utilisation of HIV services in Uganda.

Methods: Interviews and focus group discussions were conducted in Mbale and Jinja districts of Uganda between June and October 2010. Participants were men and women living with HIV (n = 40), their family members (n = 10) and health providers (n = 15). Inductive analysis was used to identify mechanisms through which stigma and masculinity were linked.

Results: Our findings showed that HIV stigma and masculinity did not exist as isolated variables, but as intersecting phenomena that influenced men's participation in HIV services. Specifically, HIV stigma threatened masculine notions of respectability, independence and emotional control, while it amplified men's risk-taking. As a result, the intersection of masculinity and HIV stigma prevented some men from i) seeking health care and accepting a 'sick role'; ii) fulfilling their economic family responsibilities; iii) safeguarding their reputation and respectability; iv) disclosing their HIV status; and v) participating in peer support groups. Participation in some peer support activities was considered a female trait and it also exacerbated HIV stigma as it implicitly singled out those with HIV. In contrast, inclusion of income-generating activities in peer support groups encouraged men's involvement as it enabled them to provide for their families, cushioned them from HIV stigma, and in the process, provided them with an opportunity to redeem their reputation and respectability.

Conclusion: To improve men's involvement in HIV services, the intersection between HIV stigma and masculinity should be considered. In particular, better integration of and linkage between gender transformative interventions that support men to reconstruct their male identities and reject signifiers of masculinity that prevent their access to HIV services, and stigma-reduction interventions that target social and structural drivers of stigma is required within HIV programmes.

Abstract  Full-text [free] access

Editor’s notes: Both stigma and masculinity can affect men’s health seeking behaviour. This article builds on previous research in Uganda on how stigma affects how men cope with HIV. It draws on the concept of intersectionality to examine how the structural vulnerabilities of stigma and masculinity intersect. It explores the perceived influence of this intersection, and the extent to which it may further disadvantage men in their participation and utilisation of HIV services. Drawing on qualitative research from eastern Uganda, this study explores how various signifiers of masculinity undermined men’s health by restricting their participation in peer support groups and HIV services. Signifiers of masculinity included physical and emotional strength, respectability, and involvement in multiple sexual relationships. Some signifiers of masculinity were also often intertwined with HIV stigma, for example men’s reluctance to adopt a sick role was reinforced by the fact that HIV was a stigmatised disease. Furthermore, shame, secrecy, a perceived sense of powerlessness, and loss of respect were often contrary to masculine notions of respect. Similarly, stigma was also shown to interact with masculine provider role identities. As a result, men sought to avoid the additional shame of not being able to provide for their families by planning to work, and therefore not prioritising clinic appointments or participation in unpaid group activities. 

Through this research, the authors argue that stigma and masculinity, rather than being understood as unilateral variables, should be considered in conjunction. This is important in order to explore how these variables might amplify or otherwise modify each other to determine men’s willingness to participate in HIV services. The authors highlight a number of implications of their research. First, HIV programmes should mobilise communities to discuss the possible harmful effects of adhering to prevalent masculine notions of risk-taking, independence, and emotional control. Second, social protection and livelihood activities targeting men living with HIV and their families should be integrated into HIV programmes and peer support group activities. Third, social support networks of men living with HIV should be bolstered in order to help men deal with stigma.

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

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

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

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

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

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

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

Abstract  Full-text [free] access

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

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HIV testing and counselling – listening to the providers

Rewards and challenges of providing HIV testing and counselling services: health worker perspectives from Burkina Faso, Kenya and Uganda.

Bott S, Neuman M, Helleringer S, Desclaux A, Asmar KE, Obermeyer CM2; the MATCH (Multi-country African Testing and Counselling for HIV) Study Group. Health Policy Plan. 2014 Sep 17. pii: czu100. [Epub ahead of print]

The rapid scale-up of human immunodeficiency virus (HIV) testing, counselling and treatment throughout sub-Saharan Africa has raised questions about how to protect patients' rights to consent, confidentiality, counselling and care in resource-constrained settings. The Multi-country African Testing and Counselling for HIV (MATCH) study investigated client and provider experiences with different modes of testing in sub-Saharan Africa. One component of that study was a survey of 275 HIV service providers in Burkina Faso, Kenya and Uganda that gathered quantifiable indicators and qualitative descriptions using a standardized instrument. This article presents provider perspectives on the challenges of obtaining consent, protecting confidentiality, providing counselling and helping clients manage disclosure. It also explores health workers' fear of infection within the workplace and their reports on discrimination against HIV clients within health facilities. HIV care providers in Burkina Faso, Kenya and Uganda experienced substantial rewards from their work, including satisfaction from saving lives and gaining professional skills. They also faced serious resource constraints, including staff shortages, high workloads, lack of supplies and inadequate infrastructure, and they expressed concerns about accidental exposure. Health workers described heavy emotional demands from observing clients suffer emotional, social and health consequences of being diagnosed with HIV, and also from difficult ethical dilemmas related to clients who do not disclose their HIV status to those around them, including partners. These findings suggest that providers of HIV testing and counselling need more resources and support, including better protections against HIV exposure in the workplace. The findings also suggest that health facilities could improve care by increasing attention to consent, privacy and confidentiality and that health policy makers and ethicists need to address some unresolved ethical dilemmas related to confidentiality and non-disclosure, and translate those discussions into better guidance for health workers.

Abstract access 

Editor’s notes: In this paper the authors investigate the experience of health workers providing HIV counselling and testing services in Burkina Faso, Kenya and Uganda. This is an under-researched topic. The respondents in the study appear to have been candid in the articulation of the challenges they face in their work. Instances of breaking the confidentiality of a person to share results with a family member or a church leader were reported. Sometimes this was to protect a partner from infection or ensure the person who had been found to be HIV-positive might access care.  Pressure from husbands or other relatives to disclose results was also reported. Many health care staff were concerned about the danger to a relationship and, most notably, to a woman’s safety that an HIV-positive result may pose. In addition, sometimes confidentiality was broken unintentionally because, for example, of the lack of a private place to share results. The majority of health workers worried about the risk of infection in their day to day work. Yet, the authors also note that in all three countries HIV care providers experience substantial rewards from their work, through saving lives and enhancing professional skills. This very welcome paper highlights the importance of documenting and monitoring HIV testing and counselling services. There is a need to support improvements in services for users and providers.

Africa
Burkina Faso, Kenya, Uganda
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Stigma and HIV – the continuing challenge

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

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

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

Design: Serial cross-sectional surveys.

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

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

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

Abstract access 

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

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

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

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

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

Abstract access 

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

Oceania
Papua New Guinea
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Do brief programmes for people who take drugs work?

Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial.

Roy-Byrne P, Bumgardner K, Krupski A, Dunn C, Ries R, Donovan D, West, II, Maynard C, Atkins DC, Graves MC, Joesch JM, Zarkin GA. JAMA. 2014 Aug 6;312(5):492-501. doi: 10.1001/jama.2014.7860.

Importance: Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance).

Objective: To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual.

Design, setting, and participants: A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1 621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points.

Interventions: Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433).

Main outcomes and measures: The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior.

Results: Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, beta = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, beta = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes.

Conclusions and relevance: A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

Abstract access 

Editor’s notes: As well as injecting drug use, in some settings, people with problematic use of drugs are at increased risk of HIV. There has been a growing use of brief programmes to reduce drug use and drug-related harm. This is despite a gap in evidence about whether such short activities work or not. This paper presents the findings from a large randomised controlled trial. The trial examined the effectiveness of brief programmes for reducing drug use and increase admission to specialist substance abuse services, compared to an enhanced care package. The study was relatively large (n=868) with high follow-up rate (more than 87%). A range of drugs and severity of use were reported. No differences were found between the brief programme and control in relation to frequency of drug use, or medical, psychiatric, employment, family/social or legal outcomes. This finding is not surprising considering the complex problems that often accompany problematic drug use, including high levels of co-morbid mental illness. What is surprising, is that the increased uptake of specialist care and reduced use of emergency departments was significantly associated with the most severe drug use. This suggests that, for these outcomes, the programme may have had a greater effect on people who were more severe drug users. It would have been helpful if the study reported prevalence of injecting among the sample, since injecting is usually associated with more frequent drug use and drug-related harms than non-injecting. Knowing whether injecting contributed to increased severity of drug use among this sample might have helped interpret the association between the brief programme and reduced use of emergency departments among people who were severe users. This paper rightly urges caution in rolling out brief programmes for a broad spectrum of drug use in primary care settings and suggests the need for more research to examine the effectiveness of brief activities by type, mode and severity of drug use.  

Health care delivery
Northern America
United States of America
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The burden of HIV: bullying and children from HIV-affected families

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

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

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

Abstract access

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

Africa
South Africa
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