Articles tagged as "Eliminate stigma and discrimination"

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

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

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

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

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

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

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

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

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

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

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

Africa
Rwanda
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Systematic review highlights gaps in depression research in sub-Saharan Africa

Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis.

Tsai AC. J Acquir Immune Defic Syndr. 2014 May 21. [Epub ahead of print]

Objectives: To systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa.

Design: Systematic review and meta-analysis.

Methods: A systematic evidence search protocol was applied to seven bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on data collected from HIV-positive adults in any African member state of the United Nations. Random-effects meta-analysis was employed to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity.

Results: Of 1 117 records initially identified, I included 13 studies of 5 373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach's alpha ranged from 0.63-0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% (95% CI, 20.5-39.4), while the pooled prevalence of major depressive disorder was 13.9% (95% CI, 9.7-18.6). The Center for Epidemiologic Studies-Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI, 0.73-0.87) for detecting major depressive disorder.

Conclusions: Depression screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.

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Editor’s notes: This is the first systematic review of depression screening and diagnostic instruments among HIV-positive people in sub-Saharan Africa. The depression treatment gap for people living with HIV in high-income countries is considerable, and is likely to be even greater in sub-Saharan Africa. The eligible studies in this review were geographically concentrated in southern and eastern Africa. Prevalence of depression overall was high, but was substantially lower among people who had initiated HIV treatment than among people who had not. Additionally, depression prevalence estimates were twice as high when using screening tools rather than diagnostic criteria, indicating a high false positivity rate. This systematic review highlights critical areas for future research, particularly in validating depression screening tools and in expanding investigation of HIV and depression co-morbidity beyond South Africa and Uganda.

Africa
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Social intolerance increases risky sexual behaviour

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

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

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

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

Africa
Malawi
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Living with HIV in resource-constrained settings: recognising the challenge

Challenging the Paradigm: anthropological perspectives on HIV as a chronic disease.

McGrath JW, Winchester MS, Kaawa-Mafigiri D, Walakira E, Namutiibwa F, Birungi J, Ssendegye G, Nalwoga A, Kyarikunda E, Kisakye S, Ayebazibwe N, Rwabukwali CB. Med Anthropol. 2014 Mar 24. [Epub ahead of print]

Recently HIV has been framed as a 'manageable' chronic disease in contexts in which access to effective care is reliable. The chronic disease paradigm emphasizes self-care, biomedical disease management, social normalization, and uncertainty. Data from a longitudinal study of patients (N=949) in HIV care at two sites in Uganda, collected through semi-structured interviews and ethnographic data, permit examination of the salience of this model in a high burden, low resource context struggling to achieve the promise of a manageable HIV epidemic. Our data highlight the complexity of the emerging social reality of long-term survival with HIV. Participants struggle to manage stigma as well as to meet the costs involved in care seeking. In these settings, economic vulnerability leads to daily struggles for food and basic services. Reconceptualizing the chronic disease model to accommodate a 'social space', recognizing this new social reality will better capture the experience of long-term survival with HIV.

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Editor’s notes: Antiretroviral therapy (ART) is enabling many people living with HIV, who have access to the drugs, to live into older age. As a consequence there have been increasing calls for HIV-infection to be treated as a chronic condition, like diabetes or hypertension.  In this paper the authors remind us that many factors make living with HIV different from other conditions, particularly in resource-constrained settings. The persistence of stigma and discrimination can make seeking and sustaining treatment difficult. Worries over side-effects, problems with drug supplies and the economic burden of accessing treatment and adequate food can make living with HIV unmanageable.  The authors illustrate very clearly through their findings that the ‘normalisation’ of HIV in people’s lives can mean coming to terms with new and often difficult challenges as they manage the hardships and worries they face on a day to day basis.

Africa
Uganda
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Masking diversity – the problems with labels for key populations

'Mobile men with money': HIV prevention and the erasure of difference.

Aggleton P, Bell SA, Kelly-Hanku A. Glob Public Health. 2014;9(3):257-70. doi: 10.1080/17441692.2014.889736. Epub 2014 Mar 4.

Mobile Men with Money is one of the latest risk categories to enter into HIV prevention discourse. Used in countries in Asia, the Pacific and Africa, it refers to diverse groups of men (e.g. businessmen, miners and itinerant wage labourers) who, in contexts of high population movement and economic disparity, find themselves at heightened risk of HIV as members of a 'most-at-risk population', or render others vulnerable to infection. How adequate is such a description? Does it make sense to develop HIV prevention programmes from such understandings? The history of the epidemic points to major weaknesses in the use of terminologies such as 'sex worker' and 'men who have sex with men' when characterising often diverse populations. Each of these terms carries negative connotations, portraying the individuals concerned as being apart from the 'general population', and posing a threat to it. This paper examines the diversity of men classified as mobile men with money, pointing to significant variations in mobility, wealth and sexual networking conducive to HIV transmission. It highlights the patriarchal, heteronormative and gendered assumptions frequently underpinning use of the category and suggests more useful ways of understanding men, masculinity, population movement, relative wealth in relation to HIV vulnerability and risk.

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Editor’s notes: Criticism of the use of labels to identify groups of people considered to be at high risk of HIV infection is not new, but this paper serves as a timely reminder of the dangers of such labels and abbreviations. The authors explain why a term that has entered common usage in recent years ‘mobile men with money’, is inappropriate. They argue that the label plays to stereotypes of men as powerful risk takers and, usually, women as their vulnerable victims. The use of the term hides the diversity of men who move around because of their work and other activities, who may be in very different professions and circumstances. It also suggests that mobility is a negative activity, overlooking the great economic and other benefits of migration. They argue that the term is not helpful for HIV programming or activities.  It is unhelpful because it fails to take account of the structural factors that influence and shape the risks many men and women, face. It is often tempting to make use of abbreviations and catchy phrases in our work. This paper helps to remind us why we need to think carefully about terminology and labelling.

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Urgent need to focus HIV prevention efforts on mobile men who have sex with men in India

The effect of mobility on sexual risk behaviour and HIV infection: a cross-sectional study of men who have sex with men in southern India.

Ramesh S, Mehrotra P, Mahapatra B, Ganju D, Nagarajan K, Saggurti N. Sex Transm Infect. 2014 Mar 26. doi: 10.1136/sextrans-2013-051350. [Epub ahead of print]

Objectives: Mobility is an important factor contributing to the spread of HIV among key population at risk for HIV; however, research linking this relationship among men who have sex men (MSM) is scarce in India. This study examines the association between mobility and sexual risk behaviour and HIV infection among MSM in southern India.

Methods: Data are drawn from a cross-sectional biobehavioural survey of 1 608 self-identified MSM from four districts of Andhra Pradesh in India, recruited through a probability-based sampling in 2009-2010. Logistic regression models were used to estimate odds ratios and 95% CIs for sexual risk behaviours (unprotected sex with any male partner) and HIV infection based on the mobility status (travelled and had sex in the past year) after adjusting for sociodemographics and risk behaviours.

Results: Of the 1 608 MSM, one-fourth (26%) were mobile. Of these, three-fourths had travelled across districts but within the state (56%), and one-fifth (20%) across states. As compared to non-mobile MSM, a higher proportion of MSM who were mobile across districts (adjusted (OR=1.42, 95% CI 1.04 to 1.95) or states (adjusted OR=3.20, 95% CI 1.65 to 6.17) reported having unprotected sex with any male sexual partner. Further, mobility across districts (adjusted OR=1.43, 95% CI 1.01 to 2.03) or states (adjusted OR=2.45, 95% CI 1.46 to 4.10) was significantly associated with HIV infection.

Conclusions: Mobile MSM have a higher likelihood of contracting HIV. Interventions extending the ways to reach out to MSM with greater mobility may augment ongoing efforts to reduce the spread of HIV/AIDS in India.

Abstract   Full-text [free] access 

Editor’s notes: Men who have sex with men are a key group for HIV prevention in India and many other settings. In India, MSM are a socially marginalised group, and people who tend to travel geographically are likely to have relatively little contact with prevention services. This study attempted to better understand the degree and pattern of mobility for this vulnerable group, in order to guide future programmes. The data, from a large cross-sectional survey in Andhra Pradesh, showed a high degree of mobility. It also showed that mobility was significantly associated with higher risk sexual behaviour and with HIV prevalence. The study highlights the need to renew efforts to focus prevention services on the hard-to-reach population of mobile men who have sex with men.

Asia
India
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Female sex workers in Iran require urgent support to combat HIV, other sexually transmitted infections, and drug use

The prevalence of human immunodeficiency virus and sexually transmitted infections among female sex workers in Shiraz, South of Iran: by respondent-driven sampling

Kazerooni PA, Motazedian N, Motamedifar M, Sayadi M, Sabet M, Lari MA, Kamali K. Int J STD AIDS. 2014 Feb;25(2):155-61. doi: 10.1177/0956462413496227. Epub 2013 Jul 19.

As a concentrated epidemic, human immunodeficiency virus (HIV) is spreading rapidly in one or more groups in Iran, but in the general population its prevalence is relatively low. Female sex workers (FSWs) and their partners are at greater risk for HIV infection. To determine the prevalence of HIV and sexually transmitted infections (STIs) including gonorrhoea, chlamydia, herpes simplex type 2 and syphilis among FSWs. We conducted a cross-sectional study of 278 FSWs in Shiraz, by using respondent-driven sampling, from June to March 2010. The recruitment chain started with 14 seeds, and FSWs were tested for HIV, syphilis, herpes simplex type 2, gonorrhoea and chlamydia. HIV prevalence was 4.7% (13/278); the most prevalent STI was herpes simplex type 2, 9.7% (27/278), followed by chlamydia 9% (25/278), gonorrhoea 1.4% (4/278) and syphilis (0/278). The FSWs reported drug use (69.9%) of which 16.4% had history of injecting drug use. Unprotected sex in the past month was reported by 24.4% of FSWs. Urgent education and risk reduction programmes are needed in this population.

Abstract access 

Editor’s notes: This paper describes the first cross-sectional study on HIV prevalence in female sex workers (FSWs) in Shiraz city in Iran. This city has some of the highest rates of HIV, sexually transmitted infections (STIs), and drug use in the country. The study was conducted using respondent driven sampling. Despite a fairly aggressive seeding strategy and a relatively long timeline, the study population was 278. The sample is reported to have reached equilibrium at this number; however it is unclear whether the seeds reflected the diversity of the population. FSWs are considered a hidden population in Iran, which could make it difficult to fully comprehend the depth of diversity within this group. Cultural, religious, and legal contexts in Iran make it difficult to reach populations such as FSWs, with health services and education. This can account for the growth in rates of HIV and other STIs in this population, and in Iran more generally. Overall, cases in HIV are estimated to rise in the country from 89 000 in 2009 to 106 000 in 2014. The HIV prevalence in this study was measured at 4.7%, with high rates of drug abuse at 69.9%. As expected, drug use was highly correlated with HIV prevalence. HSV-2 and gonorrhoea were the most prevalent STIs. FSWs reported fairly low rates of condom use overall, and as in other populations of FSWs, higher rates were seen with clients than with regular partners. Additionally, low rates of condom use were reported, especially for anal and oral sex. This important study sheds light on an otherwise hidden population and highlights the need for education and outreach of health services tailored to this population. 

Asia
Iran (Islamic Republic of)
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Stigma from health care professionals inhibits HIV testing among men who have sex with men in Viet Nam

'Never testing for HIV' among men who have sex with men in Viet Nam: results from an internet-based cross-sectional survey.

García MC, Duong QL, Mercer LE, Meyer SB, Ward PR. BMC Public Health. 2013 Dec 28;13(1):1236. doi: 10.1186/1471-2458-13-1236.

Background: Men who have sex with men in Viet Nam have been under-studied as a high-risk group for HIV infection, and this population's percentage and determinants of HIV testing have not been comprehensively investigated.

Methods: A national Internet-based survey of self-reported sexual and health seeking behaviours was conducted between August and October 2011 with 2 077 Vietnamese men who had sex with men in the last twelve months to identify the frequency of 'never testing for HIV' among Internet-using MSM living in Viet Nam, as well as the factors associated with this HIV-related high-risk behavior. Logistic regression analyses were conducted to assess the demographic characteristics and behaviours predicting never testing for HIV.

Results: A total of 76.5% of men who have sex with men who were surveyed reported never having been voluntarily tested for HIV. Predictors of never being tested included having a monthly income less than VND 5 Million, being a student, using the Internet less than 15 hour per week, and not participating in a behavioural HIV intervention.

Conclusions: Never testing for HIV is common among Internet-using men who have sex with men in Viet Nam. Given the dangerously high prevalence of this high-risk behaviour, our findings underscore the urgent need for segmented and targeted HIV prevention, care and treatment strategies, focusing on drastically reducing the number of men who have sex with men never testing for HIV in Viet Nam.

Abstract  Full-text [free] access

Editor’s notes: There is growing concern about new and resurging epidemics among men who have sex with men (MSM) globally. Previous data from Viet Nam have estimated HIV prevalence of around 20%. The low rate of HIV-testing found in this fairly large study of men who reported having sex with men in the past 12 months, is therefore quite alarming. The most common reasons for not having tested were an assumption of being HIV-negative, stigma (from health professionals), fear associated with testing and lack of knowledge about where to go to be tested. This study highlights the critical gaps in HIV testing in this setting and the urgent need to focus sexual health resources on the provision of sexual health services for MSM free from stigma and discrimination. The study also highlights the need for increasing awareness of the availability and importance of HIV testing among sexually active MSM.

Asia
Viet Nam
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To disclose or not disclose: the reasons for early HIV status disclosure or nondisclosure in Uganda

Early HIV disclosure and nondisclosure among men and women on antiretroviral treatment in Uganda.

Winchester MS, McGrath JW, Kaawa-Mafigiri D, Namutiibwa F, Ssendegye G, Nalwoga A, Kyarikunda E, Birungi J, Kisakye S, Ayebazibwe N, Walakira E, Rwabukwali CB.  AIDS Care. 2013 Oct;25(10):1253-8. doi: 10.1080/09540121.2013.764386. Epub 2013 Jan 29.

Efforts to expand access to HIV care and treatment often stress the importance of disclosure of HIV status to aid adherence, social support, and continued resource mobilization. We argue that an examination of disclosure processes early in the process of seeking testing and treatment can illuminate individual decisions and motivations, offering insight into potentially improving engagement in care and adherence. We report on baseline data of early HIV disclosure and nondisclosure, including reasons for and responses to disclosure from a cohort of men and women (n=949) currently accessing antiretroviral treatment in two regions of Uganda. We found early disclosures at the time of suspicion or testing positive for HIV by men and women to be largely for the purposes of emotional support and friendship. Responses to these selected disclosures were overwhelmingly positive and supportive, including assistance in accessing treatment. Nonetheless, some negative responses of worry, fear, or social ostracism did occur. Individuals deliberately chose not disclose their status to partners, relatives, and others in their network, for reasons of privacy or not wanting to cause worry from the other person. These data demonstrate the strategic choices that individuals make early in the course of suspicion, testing, and treatment for HIV to mobilize resources and gain emotional or material support, and similarly their decisions and ability to maintain privacy regarding their status.

Abstract access

Editor’s notes: Efforts to expand access to HIV treatment stress the importance of HIV disclosure to access social support and resources needed to maintain treatment. However, for HIV- positive individuals, disclosure has potential benefits and risks. This study explored the reasons for early disclosure, immediately following suspicion of infection, testing, or diagnosis, as well as the reasons for intentional nondisclosures among men and women receiving antiretroviral treatment in Uganda. Although reasons to disclose varied widely, early disclosures to spouses, siblings and relatives garnered emotional support and friendship. Both genders reported few negative responses. Most participants reported withholding known HIV status for privacy or to protect others because HIV status of one member of a social network may stigmatize another. Nondisclosure was sometimes due also to having no reason to tell anyone outside of one’s immediate network. Within networks, individuals deemed too young, too old, or likely to gossip were sometimes excluded from disclosure.  

Africa
Uganda
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