Self-Stigma Reduction Interventions for People Living with HIV/AIDS and Their Families: A Systematic Review

Interventions for stigma reduction in HIV treatment and prevention designed to enhance antiretroviral uptake and adherence: A systematic review

HIV remains a significant public health burden worldwide, especially in developing countries, despite the availability of effective prevention and treatment modalities, namely PrEP and ART, respectively. HIV-related stigma is a significant barrier to the optimal uptake or adherence to ART or PrEP in vulnerable populations. Therefore, there is a need for effective interventions that can address HIV-related stigma and improve adherence to ART or PrEP in vulnerable populations. This systematic review aimed to identify interventions that can effectively reduce HIV-related stigma and improve adherence to ART or PrEP in vulnerable individuals. A systematic review methodology following the PRISMA guidelines was used. The sources of information included MEDLINE (via PubMed search engine), Embase, Scopus, Web of Science, CINAHL, and PsycINFO. Studies were eligible if they were randomized controlled trials (RCTs) or quasi-experimental studies investigating the effectiveness of any intervention addressing HIV-related stigma among persons living with HIV and improving ART/PrEP adherence. We adopted a narrative synthesis approach to present our findings. For quality appraisal of included studies, we used Cochrane Risk of Bias (RoB 2) tool.Eight RCTs, but no quasi-experimental studies, met the eligibility criteria. Among the seven RCTs on ART adherence, four investigated the effectiveness of cognitive behavioral components (two studies showing positive impact on stigma reduction and ART adherence). Other effective interventions that improved ART adherence while reducing HIV-related stigma included empowerment program and youth peer-mentoring. Only one study focused on PrEP (comprising motivational interviewing, client-centered counseling), which showed stigma reduction and PrEP adherence. Although many interventions have the promise of HIV stigma reduction while simultaneously improving medication adherence, larger scale studies are needed for generalizability. The heterogeneity in measurement instruments for ART/PrEP adherence underscores the need for standardized scales. Cognitive behavioral therapy, empowerment interventions, youth peer-mentoring, motivational interviewing, and client-centered counseling all show effectiveness in reducing HIV self-stigma, while simultaneously improving medication adherence. Future studies should consider the inclusion of diverse populations and refining interventions to address HIV- stigma, especially about PrEP. It is critical to incorporate validated measurement tools to enhance comparability across research endeavors to address the complex interplay between stigma and adherence. PROSPERO number: CRD42023455610.

Interventions and Their Effectiveness to Reduce HIV-Related Stigma Among Women Living With HIV: A Systematic Review Protocol

Background

HIV-related stigma is a significant barrier to accessing public health resources and achieving health equity in women living with HIV (WLWH). The complexity of eliminating stigma against WLWH is compounded by the dual characteristics of HIV and its chronic nature. In addition, WLWH often face weak social support. They experience social alienation and isolation. They also have difficulties in self-identification and finding a sense of belonging within the new identity associated with their condition. These factors present considerable challenges to interventions aimed at combating HIV-related stigma among WLWH. The purpose of this review is to identify interventions aimed at alleviating HIV-related stigma among WLWH and evaluate their effectiveness.

Methods

A systematic search of published studies from the inception of the databases to December 2024 will be conducted in China National Knowledge Infrastructure (CNKI), Wanfang Data, Chinese Scientific Journal Database (VIP), China Biomedical Literature Service System (SinoMed), MEDLINE (OVID), Embase(OVID), CINAHL (EBSCO), ProQuest, Scopus, Cochrane Library to evaluate the effects of health promotion interventions on HIV-related stigma among WLWH. Two reviewers will independently assess the inclusion of each study, with any disagreements resolved by a third reviewer. Data will be extracted using predefined tables in accordance with best practices. Study quality will be assessed using the Effective Public Health Practice Project Quality Assessment Tool. A narrative synthesis of all studies will be presented, with appropriate statistical techniques applied to synthesize effectiveness data where feasible.

Results

The results of this review will be disseminated through publication in a peer-reviewed journal and shared online and on social media using accessible language and relevant infographics.

Conclusion

This review evaluates health promotion interventions for reducing HIV-related stigma among WLWH, identifying effective types and contexts. It addresses methodological strengths and weaknesses, providing policymakers insights into impactful interventions for global health and social care systems.

Systematic Reviews Registration

The protocol was registered in PROSPERO (CRD42024571145).

Efficacy Testing of a Culturally Relevant Stigma Reduction Intervention for Women Living With HIV in Tanzania: Protocol for a Randomized Controlled Trial

ABSTRACT

HIV-related stigma impedes HIV prevention and treatment and affects the health and quality of life of people living with HIV. Evidence-based internalized stigma reduction interventions are an identified gap in the response to HIV stigma. Our protocol article describes the methods and procedures for a randomized controlled trial in Tanzania to test the preliminary efficacy of the Labda Siku Moja (Maybe Someday) internalized stigma reduction intervention for women living with HIV on the proximal outcomes of internalized stigma, coping self-efficacy, self-esteem, and resilience, which we hypothesize are the mechanisms of change through which the intervention would work to improve distal clinical and behavioral outcomes. In addition, our study will provide data on implementation feasibility. If this preliminary efficacy trial demonstrates intervention effect on the proximal outcomes, it will signal that a larger trial testing the effect on downstream distal clinical and behavioral outcomes is warranted. Our study will add to the nascent literature on rigorously evaluated internalized HIV stigma interventions.

Improving NGOs' participation in implementing HIV preventive interventions: a case of adolescents with high-risk behaviors in Iran

BACKGROUND

The study aimed to identify the obstacles that NGOs face in their participation in implementing HIV preventive interventions among adolescents with high-risk behaviors in Iran and to propose interventions to enhance their involvement.

METHODS

The study employed a qualitative approach in three phases to identify barriers and solutions to NGOs' participation in HIV preventive interventions. First, 56 semi-structured interviews, four focus group discussions (FGDs), and a document review were conducted with diverse stakeholders, using a purposive sampling strategy combining maximum variation sampling with a snowballing approach. Participants were sampled from relevant backgrounds in health policymaking, public participation, or communicable disease. Data from interviews and FGDs were audio-recorded, transcribed, and analyzed using an inductive content analysis. Second, a scoping review was performed, utilizing databases such as PubMed, Web of Science, ProQuest, and Google Scholar. A policy brief from the first two phases informed a one-day multi-stakeholder policy dialogue with 16 selected policy actors. This session was audio-recorded, transcribed, and analyzed through content analysis.

RESULTS

We identified various challenges faced by NGOs, including those related to the unique features of HIV services, such as difficulty in case finding and constant provision of preventive care. Severe challenges included weak NGOs' performance, insufficient capabilities, and insufficient support from the government, resulting in undesirable constructive collaboration. Tailored strategies were developed, such as the empowerment of NGOs, enhancing public health literacy, modifying the process of identifying eligible NGOs, clarifying key processes for NGOs' involvement, response to COVID-19, increasing adolescent engagement, advocating for removing the stigma from active NGOs, increasing support for active NGOs, organizing communication networks and collaboration, and strengthening governance arrangements.

CONCLUSIONS

NGOs' participation in HIV prevention can facilitate the alignment of interventions with the specific needs of at-risk populations. However, there are obstacles to full NGOs' participation from both NGO and government perspectives, necessitating several measures to address these challenges. These measures are imperative for fostering constructive and sustained collaboration between NGOs and the government. The significance of this study lies in its emphasis on such collaboration, particularly in low-resource settings, which is crucial for nations committed to authentically realizing the goal of 'health for all, by all,' alongside genuine community participation.

TRIAL REGISTRATION

NA.

Positive, Open, Proud: an adapted disclosure-based intervention to reduce HIV stigma

HIV stigma among people living with HIV (PLWH) is well documented and linked to adverse physical and mental health outcomes among this population. Further, stigma may affect HIV disclosure decisions, which has important individual and public health implications. For women, HIV stigma and disclosure may be compounded by gender-based discrimination and violence. Despite the ill effects of HIV stigma, particularly for women, few evidence-based disclosure interventions to reduce stigma among PLWH exist. However, there is strong evidence for the efficacy of Honest, Open, Proud (HOP), a disclosure-based stigma-reduction intervention for people with mental illness. Given that mental illness and HIV are similar in that they are both stigmatized yet concealable conditions, we propose using the ADAPT-ITT model to adapt HOP into Positive, Open, Proud, a disclosure-based stigma-reduction intervention for PLWH, describing its unique potential for women living with HIV.

Measuring internalized health-related stigma across health conditions: development and validation of the I-HEARTS Scale

BACKGROUND

Health-related stigma and its internalization among individuals with chronic health conditions contribute to impaired mental and physical health and quality of life. Research on health-related stigma has been siloed, with disease-specific measures that may not capture the experiences of individuals with multiple health conditions and that prevent comparisons across health conditions. The current study aimed to develop and test a transdiagnostic measure of internalized health-related stigma for use among adults with different physical health conditions.

METHODS

An existing measure of internalized mental health stigma was adapted to assess stigma due to chronic physical health conditions following COSMIN procedures, with input from advisory boards of community members living with a range of stigmatized health conditions (obesity, type 1 and type 2 diabetes, skin diseases, HIV, chronic pain, and cancers) and of health professionals who specialized in these conditions. The new Internalized Health-Related Stigma (I-HEARTS) Scale was tested in an online sample of 300 adults with these health conditions, recruited from ResearchMatch. Additional psychosocial measures of mental health and quality of life were administered, and participants provided information about their health conditions and demographic characteristics. Exploratory factor analysis and tests of reliability and validity were conducted to determine the psychometric properties of the I-HEARTS Scale, and k-means clustering and receiver of characteristic curve analysis were used to determine a clinically meaningful cutoff score indicating high levels of internalized stigma.

RESULTS

Factor analysis results yielded a 25-item scale with a 3-factor solution, with subscales of Perceived and Anticipated Stigma, Stereotype Application and Self-Devaluation, and Stigma Resistance. Psychometric properties for internal consistency, inter-item and item-total correlations, and test-retest reliability were strong. Certain demographics (e.g., younger age) and characteristics related to health conditions (e.g., greater symptom severity) were associated with higher levels of internalized stigma. I-HEARTS Scale scores correlated moderately to strongly with related but distinct psychosocial measures, and a cutoff score of 3.40 or higher on the 1-7 rating scale was determined to indicate clinically meaningful levels of internalized stigma.

CONCLUSIONS

The I-HEARTS Scale is a reliable and valid measure for the assessment of internalized health-related stigma among adults with varied stigmatized chronic health conditions. STUDY PRE-REGISTRATION: https://osf.io/84c5d/?view_only=87238512f6d6475c87f8f64280a8a15f .

Does Mindfulness Improve Intergroup Bias, Internalized Bias, and Anti-Bias Outcomes?: A Meta-Analysis of the Evidence and Agenda for Future Research

Whereas mindfulness has been shown to enhance personal well-being, studies suggest it may also benefit intergroup dynamics. Using an integrative conceptual model, this meta-analysis examined associations between mindfulness and (a) different manifestations of bias (implicit/explicit attitudes, affect, behavior) directed toward (b) different bias targets (outgroup or ingroup, e.g., internalized bias), by (c) intergroup orientation (toward bias or anti-bias). Of 70 samples, 42 (N = 3,229) assessed mindfulness-based interventions (MBIs) and 30 (N = 6,002) were correlational studies. Results showed a medium-sized negative effect of MBIs on bias outcomes, g = -0.56, 95% confidence interval [-0.72, -0.40]; I(2;3)2: 0.39; 0.48, and a small-to-medium negative effect between mindfulness and bias for correlational studies, r = -0.17 [-0.27, -0.03]; I(2;3)2: 0.11; 0.83. Effects were comparable for intergroup bias and internalized bias. We conclude by identifying gaps in the evidence base to guide future research.

Interventions to Reduce Skin-related Self-stigma: A Systematic Review

Self-stigma beliefs are common among people with visible chronic skin diseases and can negatively affect their quality of life and psychosocial wellbeing. Hence, evidence-based interventions are urgently needed. The objective for this systematic review was to summarize research on available interventions and evaluate their benefits and limitations. Following PRISMA guidelines, we conducted an electronic database search of four databases (EMBASE, PsycINFO, PubMed, Web of Science). Studies were eligible if they (a) investigated interventions to reduce self-stigma in adults with chronic skin disease, (b) were original empirical articles, and (c) were written in English or German. Two independent reviewers conducted the abstract and full text screening as well as data extraction. The quality of the included studies was evaluated using the Critical Appraisal Skills Programme checklists. The initial search yielded 5811 abstracts; of which, 23 records were eligible. Studies addressed a broad range of skin conditions, and interventions ranged from social skills training, counselling and self-help to psychosocial and behavioural interventions. Overall, interventions had mostly positive effects on self-stigma and related constructs. However, the study quality was heterogeneous, and further efforts to develop, thoroughly evaluate and implement interventions tackling self-stigma in multiple skin conditions and languages are warranted.

Changes in HIV Internalized and Experienced Stigmas and Social Support After an Urban Gardens and Peer Nutritional Counseling Intervention Among People With HIV and Food Insecurity in the Dominican Republic

BACKGROUND

Food insecurity and HIV-related stigma negatively affect HIV outcomes. Few studies have examined how food security interventions affect HIV-related stigma and social support.

SETTING

Two HIV clinics in the Dominican Republic.

METHODS

A pilot cluster randomized controlled trial of an urban gardens and peer nutritional counseling intervention was conducted to examine outcomes of HIV-related stigmas and social support. Adult patients (≥18 years of age) with moderate or severe household food insecurity and evidence of suboptimal ART adherence and/or a detectable viral load were enrolled; standard measures of internalized and experienced stigmas and social support were collected at baseline and at 6 and 12 months. Intervention clinic participants received training and materials from agronomists for a home garden, 3-4 sessions of nutritional counseling from the clinic's peer counselor, and a garden produce cooking workshop facilitated by professional nutritionists.

RESULTS

Of 109 study participants (46 intervention and 63 control), 103 (94%) completed 12-month follow-up. Difference-in-differences multivariate longitudinal linear regressions adjusting for sociodemographic factors found that intervention participants had reduced internalized stigma by 3.04 points (scale 0-32) at 12 months (P = 0.002); reduced probability of experiencing HIV-related stigma or discrimination in the past 6 months (20 percentage points at 6 months, P = 0.05 and 25 percentage points at 12 months, P = 0.02); and modestly improved social support at 12 months (1.85 points on 30-pt scale, P = 0.093).

CONCLUSION

A fully powered, larger trial is needed to establish the efficacy of the intervention and assess pathways by which the intervention may improve HIV stigma and social support.

COVID-19 Incidence, Risk Factors, Impact, and Related Stigma Among a Cohort of Persons With HIV in Washington, DC

BACKGROUND

Studies on the incidence of COVID-19 among persons with HIV (PWHs) present varied results. Few studies have investigated the impact of COVID-19 infection on health and socioeconomic factors or COVID-19 stigma. We sought to measure the incidence and severity of COVID-19 infection among a cohort of PWHs, characterize associated risk factors and impact, and document perceptions of COVID-19-related stigma.

METHODS

Data for this cross-sectional study come from the COVID-19 survey of participants in the DC Cohort longitudinal study from October 30, 2020, through December 31, 2022. Survey results were linked to electronic health records, including HIV laboratory test results and COVID test results. We conducted analyses comparing demographic, socioeconomic, HIV measures, and stigma among those with and without self-reported COVID-19.

RESULTS

Of 1972 survey respondents, 17% self-reported COVID-19 infection, with the greatest incidence in the Omicron wave of the pandemic. We found statistically significant differences by age, employment status, essential worker status, education, and household income. Longer duration of HIV diagnosis was associated with greater incidence of COVID-19. PWHs who were overweight or obese had a greater incidence of COVID-19 compared with those who were not. Over 40% of PWHs with COVID-19 reported experiencing at least 1 form of COVID-19-related stigma.

CONCLUSION

We observed a high incidence of COVID-19 infection among PWHs in DC. Furthermore, a substantial proportion of PWHs with COVID-19 reported experiencing COVID-19-related stigma. These findings add to the existing literature on COVID-19 coinfection among PWHs and highlight the need for awareness and support for those experiencing COVID-19 stigma.

Scaling Up HIV Self-Testing and Linkage to Care Among Women Who Exchange Sex and/or Use Drugs in Kazakhstan

HIV testing is the point of entry for linkage to treatment and prevention and is critically important to ending the HIV epidemic. HIV self-testing (HST) is an acceptable, user-controlled tool that can address testing barriers, which is especially important for populations who need to test frequently, like women who exchange or trade sex for money or other needed resources (WES) and women who use drugs. HST is feasible and acceptable among WES, but research among WES who also use drugs is limited, particularly in places like Kazakhstan, where HIV rates remain high and where scale-up of HST and pre-exposure prophylaxis (PrEP) is in process. To develop effective programming, there is a need to develop tailored services for WES and/or use drugs that address key barriers. We discuss opportunities to increase HST and linkage to services among WES and/or use drugs in Kazakhstan, with a focus on stigma reduction.

Preliminary Impact of Group-Based Interventions on Stigma, Mental Health, and Treatment Adherence Among Adolescents Living with Human Immunodeficiency Virus in Uganda

OBJECTIVE

To examine the preliminary impact of group cognitive behavioral therapy and multiple family group-based family strengthening to address HIV stigma and improve the mental health functioning of adolescents living with HIV in Uganda.

STUDY DESIGN

We analyzed data from the Suubi4Stigma study, a 2-year pilot randomized clinical trial that recruited adolescents living with HIV (10-14 years) and their caregivers (n = 89 dyads), from 9 health clinics. We fitted separate three-level mixed-effects linear regression models to test the effect of the interventions on adolescent outcomes at 3 and 6 months post intervention initiation.

RESULTS

The average age was 12.2 years and 56% of participants were females. Participants in the multiple family group-based family strengthening intervention reported lower levels of internalized stigma (mean difference = -0.008, 95% CI = -0.015, -0.001, P = .025) and depressive symptoms at 3 months (mean difference = -0.34, 95% CI = -0.53, -0.14, P < .001), compared with usual care. On the other hand, participants in the group cognitive behavioral therapy intervention reported lower levels of anticipated stigma at 3 months (mean difference = -0.039, 95% CI = -0.072, -0.006), P = .013) and improved self-concept at 6 months follow-up (mean difference = 0.04, 95% CI = 0.01, 0.01, P = .025).

CONCLUSION

Outcome trends from this pilot study provide compelling evidence to support testing the efficacy of these group-based interventions on a larger scale.

TRIAL REGISTRATION

The study is registered in the Clinical trials.gov database (Identifier #: NCT04528732).

Understanding the impact of a residential housing program for people living with HIV/AIDS: results from a realist evaluation

BACKGROUND

In Canada, the Public Health Agency surveillance of new HIV cases has demonstrated annual increasing rates since 2020. The rates of new HIV cases are highest in the province of Saskatchewan.

OBJECTIVES

The aim of the project was to conduct a resident-oriented realist evaluation of an innovative supportive housing programme, Sanctum, for people living with HIV/AIDS who also face social care issues, such as homelessness. This project took place in Saskatchewan, a province that is seeking innovative approaches to improve quality of life and HIV/AIDS management for its citizens. Our evaluation addressed how and why participants were successful (or not) within the Sanctum programme.

DESIGN AND SETTING

Sanctum is a housing programme located in an inner-city location within the province of Saskatchewan. A unique component of this evaluation was the inclusion of an individual with lived experience, a resident partner, as a member of the research team.

PARTICIPANTS

11 recent Sanctum graduates, seven men and four women, were recruited for client partner-led in-depth, semistructured interviews.

INTERVENTIONS

Prior to the evaluation, we developed a realist programme theory with potential causal explanations, known as context-mechanism-outcomes (CMO) configurations. Interview data from the evaluation and ongoing discussions with Sanctum board members and our resident partner were used to test, refine and validate the final programme theory and CMO configurations.

RESULTS

CMO configurations at the micro (individual), meso (interpersonal) and macro (community) levels complement the over-arching programme theory. Key findings were the importance of Sanctum's harm reduction philosophy, accompanied by a non-judgmental and patient-oriented approach. Participants were supported to reduce risky behaviour, improve self-care management and develop healthier relationships within a 'safe' home-like setting. Underlying mechanisms that contributed to participants' success in the programme included: intrinsic motivation, self-worth, belongingness, empowerment and self-efficacy. Evidence-informed recommendations are offered to support Sanctum-like programme development for individuals with holistic health needs related to HIV/AIDS diagnoses and lack of access to necessary social determinants of health.

CONCLUSIONS

Stigma associated with HIV/AIDS and living circumstances, such as homelessness, were successfully addressed using harm reduction principles and judgement-free approaches within a family-like environment.

Interventions to reduce self-stigma in people who use drugs: A systematic review

BACKGROUND

Substance use stigma is a key barrier to treatment and harm reduction engagement among people who use drugs (PWUD). Previous systematic reviews have focused on interventions to reduce stigma in healthcare providers and the public; less is known about interventions to address self-stigma among PWUD. The purpose of this review is to evaluate the evidence for substance use self-stigma reduction interventions.

METHODS

We reviewed English-language studies published between 2011 and 2023 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO #CRD42022321305). We searched seven bibliographic databases (PubMed; SCOPUS; APA PsycInfo; CINAHL; Social Work Abstracts; Sociological Abstracts; ProQuest Dissertations & Theses). This review included studies if 1) they evaluated the effectiveness of a psychosocial intervention, 2) participants were PWUD, 3) authors reported self-stigma as a primary outcome, 4) the study design was experimental or quasi-experimental. We reviewed, interpreted and reported intervention characteristics and effectiveness using narrative synthesis. We assessed study quality with the Downs & Black checklist.

RESULTS

Among 1195 screened studies, 15 met the inclusion criteria (N = 2280 PWUD). We categorized the interventions according to three approaches: psychotherapeutic (n = 8), psychoeducational (n = 5), and multimodal (n = 2). Most interventions were delivered in clinical settings (n = 11) and in a group format (n = 13). Study quality was fair-to-good and included nine randomized controlled trials (RCTs) and six quasi-experiments. Measurement heterogeneity was high, with 11 different stigma-related scales used across the 15 studies. Eleven studies showed significant favorable effects in at least one stigma measure. Six of these demonstrated positive effects in all stigma measures. Evidence was mixed for all three intervention categories; however, Acceptance and Commitment Therapy, a form of group psychotherapy, demonstrated effectiveness in four of five RCTs incorporating this approach.

CONCLUSIONS

Overall, there is promising evidence for the effectiveness of substance use self-stigma interventions, although more studies are needed to determine which approaches are most effective. Consistent conceptualization and measurement of self-stigma across studies will improve comparability in future intervention trials. Current offerings are largely limited to clinical settings and group-based formats; self-help interventions, available for other stigmatized conditions, could be developed to serve the majority of PWUD not engaged in treatment.

An Analysis of Approaches to Reduction of HIV Stigma across the World through educational interventions: A Scoping Review

Objective

To determinate the educational interventions for reducing the stigma caused by HIV worldwide.

Methods

This scoping review study analyzed all papers published from early 2000 to the end of 2022 by searching all the scientific databases, Scopus, Web of Science, PubMed, Cochrane, Embase and CINHAL. The quality assessment of the papers was done using the ROBIS tool checklist.

Results

31papers were admitted to the scoping review process. Stigma reduction intervention was founded on three parts: Society, health and therapeutic services providers, and the patients who had HIV and their families. The interventions included education on the reduction of fear, and shame, observation of protective standards, conducting tests and treatment at the above levels, as well as the support provided by the society, policymakers, religious leaders and families of patients in economic, psychological and cultural terms, together with the establishment of social centres and organization of campaigns.

Conclusion

The stigma associated with HIV is a significant obstacle before treatment, life expectancy and living quality of patients. Therefore, the stigma associated with this disease can be reduced, and the living quality of patients can be raised using approaches such as education of healthcare service providers and afflicted people, as well as economic, social, cultural, and psychological support.

The association of HIV-related stigma and psychosocial factors and HIV treatment outcomes among people living with HIV in the Volta region of Ghana: A mixed-methods study

Stigma and discrimination have been identified as significant barriers to HIV treatment among people living with HIV (PLWH). HIV stigma affects decision to seek HIV testing and early treatment. Evidence shows that HIV stigma undermines antiretroviral therapy (ART) adherence by affecting the psychological process such as adjusting and coping with social support. In Ghana, stigma toward PLWH occurs in many ways including rejection by their communities and family members, ostracism, and refusal to engage in social interactions such as eating, sharing a bed, or shaking hands. Therefore. we examined PLWH's experiences with different forms of HIV-related stigma and the impact on HIV treatment outcome in the Volta region of Ghana. We employed a convergent mixed-method approach consisting of a survey with 181 PLWH, four focus group discussions with 24 survey respondents, and in-depth interviews with six providers. We performed independent samples t-test, ANOVA, and chi-square test to test associations in bivariate analysis and analyzed qualitative data using thematic analysis. In all, 49% of survey respondents reported experiencing high internalized stigma, which was associated with high social support and depression (p<0.001). In qualitative interviews, anticipated stigma was the most salient concern of PLWH, followed by internalized and enacted stigma, which all negatively impacted HIV treatment and care. Stigma was experienced on multiple levels and affected psychosocial and treatment outcomes. Findings suggest urgent need for HIV-stigma reduction intervention among PLWH and their family, providers, and community members.

Efficacy of mobile-based educational intervention using Instructional Systems Design in promoting preventive behaviors for sexually transmitted infections among Iranian women: a randomized controlled trial

BACKGROUND

Women who are sexually active are at risk of sexually transmitted infections (STIs), which can cause serious difficulties for their reproductive health. However, despite the high global burden of STIs, most infections are preventable with education for behavioral change. The purpose of this study is to investigate the Efficacy of Mobile-Based Educational Intervention Using Instructional Systems Design in Promoting Preventive Behaviors for Sexually Transmitted Infections among Iranian Women.

METHODS

This randomized controlled trial aimed at promoting preventive behaviors related to STIs in Iranian women with an educational intervention based on the Instructional Systems Design (ISD) in 2022. The participants in this study were recruited from a single center, specifically the Health House No. 3 located in District 11 of Tehran Municipality. Two instruments were used in the present study: a) a valid scale titled: "Four-Scale of STI Preventive Behaviors", and b) a researcher-made Questionnaire titled: "Social perception affecting sexually transmitted infections (SOPESTI)". These tools contain 8 demographic items and specific questions with a total of 68 five-point Likert scales. The intervention comprised three phases: a pre-test (baseline), a training program, and two follow-up assessments (4 and 12 weeks after the start of the training program). The experimental group received education through a mobile app, while the control group received no intervention. SPSS v.26 was used, with a significance level of P < 0.05. The chi-square test, Fisher's exact test, independent t-tests, analysis of covariance (ANCOVA), and repeated measures ANOVA were used to analyze the data.

RESULTS

A total of 80 women, with a mean age of 36.524 ± 6.91 (experiment group) and 34.78 ± 8.20 (control group), respectively, participated in the trial. The study revealed a statistically significant difference in the mean score for eight domains, including STIs Knowledge, STIs Vulnerability, STIs Preventive Self-efficacy, STIs Prevention intentions, STIs Perceived social exclusion, STIs Perceived cognitive barriers, STIs Perceived social support, and STIs Perceived risks in the experiment group following the intervention compared to before the intervention (p < 0.05).

CONCLUSION

The results of this study showed that a mobile-based educational intervention based on the ISD model had a significant effect on the preventive behaviors of STIs in Iranian women. These results highlight the potential benefit of mobile health in enhancing reproductive health.

TRIAL REGISTRATION

ClinicalTrials.gov IRCT20200602047638N1. Registered on 22 May 2021 with the IRCTID, V1.0. https://www.irct.ir/trial/55632.

Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination

A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.

Prevalence and correlates of internalized stigma among adults with HIV and major depressive disorder in rural Malawi

Internalized stigma is common among individuals with sexually transmitted infections such as HIV and among those with mental health conditions such as major depressive disorder (MDD). As part of a cluster randomized trial, we investigated the prevalence and correlates of internalized stigma among adults living with comorbid HIV and MDD in rural Malawi (n = 339). We found heightened stigma toward HIV and mental illness among those in the cohort: more than half of respondents (54%) endorsed negative perceptions associated with each health condition. Internalized HIV-related stigma was higher among those with no education (p = 0.04), younger adults (p = 0.03), and those with less social support (p = 0.001). Mental illness-related stigma was elevated among those with no source of income (p = 0.001), and it was also strongly associated with HIV-related stigma (p < 0.001). Our findings highlight potential avenues for reducing internalized stigma associated with high-prevalence health conditions in Malawi.Trial registration: ClinicalTrials.gov identifier: NCT04777006.

'We are not here to enforce; we are here for the people' Factors influencing performance of contact tracing during the COVID-19 pandemic: A qualitative study

Background

Provider-initiated contact tracing (CT) is an important measure to slow down the spread of infectious diseases such as COVID-19. However, carrying out effective CT depends on the collaboration between the patient and the contact tracer. To improve CT, it is important to understand which factors influence contact tracers in being able to carry out CT during large pandemics.

Methods

We performed individual semi-structured interviews with nine contact tracers working for the COVID-19 unit of the Public Health Service (PHS) Rotterdam-Rijnmond, the Netherlands, to explore their experiences with carrying out CT. Data were collected between July 2020 and December 2020. The interview protocol was structured based on the CT tasks and guided by the literature and the framework explaining adherence to clinical practice guidelines.

Results

In general, CT seemed to be carried out satisfactorily. Individual factors (interviewing techniques and skills, attitude towards the patient and attitude towards CT), factors related to the patient (cooperativeness and engagement, emotions, language and culture and (mis)information), guideline-related factors (characteristics) and factors related to the organisation (interactions with colleagues, support from management, workload and training) were found to influence the carrying out of CT.

Conclusion

To be well prepared for future pandemics, it is important to explore strategies that can be effective to support the contact tracer in performing CT, support patients in feeling comfortable to be engaged and ways to reach more consistency in policies and protocols.

A Psychometric Evaluation and a Framework Test of the HIV Stigma Mechanisms Scale Among a Population-Based Sample of Men and Women Living with HIV in Central Uganda

HIV stigma is a critical barrier to HIV prevention and care. This study evaluates the psychometric properties of the HIV Stigma Mechanisms Scale (HIV-SMS) among people living with HIV (PLHIV) in central Uganda and tests the underlying framework. Using data from the PATH/Ekkubo study, (n = 804 PLHIV), we assessed the HIV-SMS' reliability and validity (face, content, construct, and convergent). We used multiple regression analyses to test the HIV-SMS' association with health and well-being outcomes. Findings revealed a more specific (5-factor) stigma structure than the original model, splitting anticipated and enacted stigmas into two subconstructs: family and healthcare workers (HW). The 5-factor model had high reliability (α = 0.92-0.98) and supported the convergent validity (r = 0.12-0.42, p < 0.01). The expected relationship between HIV stigma mechanisms and health outcomes was particularly strong for internalized stigma. Anticipated-family and enacted-family stigma mechanisms showed partial agreement with the hypothesized health outcomes. Anticipated-HW and enacted-HW mechanisms showed no significant association with health outcomes. The 5-factor HIV-SMS yielded a proper and nuanced measurement of HIV stigma in central Uganda, reflecting the importance of family-related stigma mechanisms and showing associations with health outcomes similar to and beyond the seminal study.

Brief cognitive behavior therapy for stigmatization, depression, quality of life, social support and adherence to treatment among patients with HIV/AIDS: a randomized control trial

OBJECTIVE

Individuals living with HIV/AIDs are at a high risk of many problems like depression, stigma, quality of life, decreased adherence to treatment, and lack of social support. The present study aimed to investigate the impact of brief-cognitive behavior therapy (B-CBT) on reducing depression and stigma and improving treatment adherence, quality of life, and social support among patients with HIV/AIDS attending antiretroviral therapy (ART).

MATERIALS AND METHODS

This randomized clinical trial was conducted at ART Clinic in the Tehsil Headquarters Hospital Shahkot Nankana Sahib from July 2021 to October 2021. After baseline screening, 126 patients met the eligibility criteria and 63 were allocated to the experimental group (EXPg = 63) and 63 to waitlist-control group (WLCg = 63). Participants' age range was from 20 to 55 years. Participants who were taking ART treatment were enrolled for the CBT treatment. Before this, all the participants completed a baseline assessment to ensure a level of severity and diagnosis. A total of eight CBT based therapeutic sessions were conducted individually with EXPg. To assess the outcomes among patients receiving ART, we used Demographic form, Patient health questionnaire, HIV stigma scale, General medication adherence scale, Multidimensional scale of perceived social support, and WHOQOL BREF scale.

RESULTS

Findings suggest that B-CBT significantly reduced the level of depression (i.e. F (1, 78) = 101.38, p < .000, η2 = .599), and social stigma (i.e. F (1, 78) = 208.47, p < .000, η2 = .787) among patients with HIV/AIDS. Furthermore, CBT substantially improved the level of adherence to treatment (i.e. F(1,78) = 24.75, p < .000, η2 = .503), social support (i.e. F (1, 78) = 128.33, p < .000, η2 = .606), and quality of life (i.e. F (1, 78) = 373.39, p < .000, η2 = .837) among patients with HIV/AIDS. Significant mean difference M(SD) on PHQ at post-analysis in the EXPg vs. WLCg was seen 1.22(0.47) vs. 2.30(0.68) and similarly, on MPSS at a post-analysis in the EXPg vs. WLCg 2.85(0.36) vs. 1.70(0.51) which indicates sound therapeutic outcomes.

CONCLUSIONS

Cognitive behavioral therapy effectively decreases the level of depression and stigma and enhances the level of social support, quality of life, and adherence to treatment among HIV/AIDS patients. It is concluded that cognitive behavior therapy is an effective treatment approach for patients with HIV/AIDS.

TRIAL REGISTRATION

Thai clinical trial registry (i.e. TCTR =  TCTR20210702002 ).

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Integrating PrEP in maternal and child health clinics in Kenya: analysis of a service availability and readiness assessment (SARA) survey

Background

Risk of HIV acquisition is high during pregnancy and postpartum, and pre-exposure prophylaxis (PrEP) is recommended for peripartum populations. Integrating PrEP into maternal and child health (MCH) clinics is feasible and acceptable. Understanding clinics' service availability and readiness is essential for effective scale up.

Methods

The PrEP in Pregnancy, Accelerating Reach and Efficiency study (PrEPARE; NCT04712994) engaged PrEP-experienced facilities previously linked to a programmatic or research study in Western Kenya to document available services and commodities via a modified service availability and readiness assessment (SARA) survey with 20 PrEP tracer items covering: staffing/guidelines, services/equipment, and medicines/commodities. Facilities' prior study engagement occurred between 2017 and 2019; SARA survey data was collected between April 2020 and June 2021. Descriptive statistics were stratified by prior study engagement. ANOVA tests assessed associations between facility characteristics and gaps. Fisher's tests assessed differences in commodity availability and stockouts.

Results

Of the 55 facilities surveyed, 60% had received PrEP training in the last two years, 95% offered PrEP integrated into MCH, and 64% and 78% had both auditory and visual privacy in PrEP and HIV testing service (HTS) delivery spaces, respectively. Supervision frequency was heterogeneous, but 82% had received a supervision visit within 3 months. Availability of commodities was variable and the most commonly unavailable commodities were PrEP in MCH (71% available) and risk assessment screening tool (RAST) and PrEP cards (60% and 75% available, respectively). The number of service and commodity gaps per facility ranged from zero to eight (median: 3; IQR: 2, 5). The most frequent gaps were: PrEP training and risk assessment cards (40% each), lack of privacy in PrEP (36%) and HIV testing services (31%) spaces, PrEP pills in MCH (29%), and PrEP cards (25%). There were no differences in mean number of gaps by county, previous study engagement, or public vs. private status. Level 4 facilities had fewer gaps (mean 2.2) than level 2, 3, and 5 facilities (mean 5.7, 4.5, and 5.3 respectively; p < 0.001).

Conclusions

PrEP service availability and readiness was generally high across MCH facilities. However, there is a need for increased frequency of provider training and supportive supervision focused on fidelity. To address key commodity stockouts such as PrEP pills, implementation of electronic logistics management information systems may be needed. Targeting these gaps is essential to effectively scale up integrated PrEP delivery, especially among facilities with limited infrastructure.

Entertainment-education to reduce internalized stigma, increase intimate partner status disclosure intentions, and increase antiretroviral medical adherence intentions: A randomized controlled trial targeting black women living with HIV in the Southern U.S

BACKGROUND

Black women in the Southern U.S. account for 67% of all new HIV diagnoses across women of all races and ethnicities. In comparison to women of other racial and ethnic identities, Black women disproportionately experience internalized stigma, lower levels of disclosure self-efficacy, and lower rates of medical adherence. The disclosure processes model hypothesizes that persons living with HIV can be disclosure avoidance oriented or disclosure approach oriented. Disclosure avoidance is facilitated by various forms of stigma and negative outcome expectations. While disclosure approach orientation is facilitated by factors such as positive disclosure attitudes and disclosure self-efficacy. Despite the important role of disclosure in ending the HIV epidemic, extant interventions are limited. Recent research suggests entertainment-education (EE) may be an effective intervention for HIV status disclosure. Entertainment-education is a persuasive strategy that consists of intentionally embedding health and social messages into entertaining content.

METHODS

The present study evaluated the comparative efficacy of the 90 DAYS film for improving internalized HIV stigma, disclosure beliefs, positive disclosure attitudes, disclosure self-efficacy, HIV disclosure intentions, and medical adherence intentions. A randomized controlled trial was employed consisting of 130 Black women living with HIV in the Southern U.S. Participants were recruited primarily via a Qualtrics panel and randomly assigned to either view the 90 DAYS film or a standard of care brochure.

RESULTS

Results indicated the EE condition significantly outperformed the brochure condition on the following outcomes: disclosure beliefs (p = .046), positive disclosure attitudes (p = .008), disclosure self-efficacy (p = .007), and intentions to disclose to an intimate partner (p = .038). Statistically significant differences were not observed for internalized stigma or medical adherence intentions.

CONCLUSION

Findings suggest that EE is an effective strategy for improving psychosocial influences of disclosure and disclosure intentions. Theoretical and practical implications of this work are discussed.

Long COVID in people living with HIV

PURPOSE OF REVIEW

It is now recognized that SARS-CoV-2 infection can have a long-term impact on health. This review summarizes the current state of knowledge regarding Long COVID in people living with HIV (PLWH).

RECENT FINDINGS

PLWH may be at elevated risk of experiencing Long COVID. Although the mechanisms contributing to Long COVID are incompletely understood, there are several demographic and clinical factors that might make PLWH vulnerable to developing Long COVID.

SUMMARY

PLWH should be aware that new or worsening symptoms following SARS-CoV-2 infection might represent Long COVID. HIV providers should be aware of this clinical entity and be mindful that their patients recovering from SARS-CoV-2 infection may be at higher risk.

A Systematic Review of the Consequences of Stigma and Stereotype Threat for Individuals With Specific Learning Disabilities

Exposure to stigma and stereotype threat is detrimental for numerous marginalized groups. Research has demonstrated that individuals with specific learning disabilities (SLDs) are vulnerable to stigmatization. The purpose of this systematic review was to summarize the studies investigating associations between SLD-related stigma and stereotype threat and psychological and academic outcomes in individuals with SLDs, as well as examine the overall effect size of these associations across studies. A total of 16 studies met inclusion criteria-12 studies (52 effect sizes) examined SLD stigma with psychological adjustment or academic outcomes, and six studies (eight effect sizes) examined SLD stereotype threat. Greater SLD stigma scores had a medium-sized and significant correlation with less self-esteem across nine effect sizes (r = -.39, p = .002). Other outcomes were not powered enough for meta-analyses, although studies generally showed that greater SLD stigma and stereotype threat was related to less optimal psychological adjustment. These results suggest that these negative experiences should be a target of intervention and support efforts for individuals with SLDs. The associations between SLD stigma and stereotype threat and academic performance outcomes were comparatively more heterogeneous and less robust. These findings highlight the need for more research on SLD-related stigma and stereotype threat.

Understanding the experiences of caregivers of HIV-exposed children under five: A phenomenological inquiry

Background

Children born to mothers with HIV require special care from the womb to the postnatal period, and caregivers involved in their care face several challenges.

Objective

This study aimed to explore caregivers' experiences providing care for HIV-exposed children under five.

Methods

This study employed a phenomenological approach. Ten caregivers of HIV-exposed children living in Jakarta, Indonesia, were selected using snowball techniques. Online in-depth interviews were conducted to collect data from September 2021 to July 2022, and thematic analysis using Colaizzi's method was performed for data analysis.

Results

The study involved ten caregivers (nine females and one male) aged between 23 and 42 years. Seven of them were mothers who tested HIV-positive, while one was an adoptive father, one was a mother's sister, and one was an aunt of HIV-exposed children. The majority of them were housewives and had a low educational background. Three themes were generated: (i) disease-transmission foreboding, (ii) prejudice against mothers and children exposed to HIV, and (iii) seeking support.

Conclusion

Caring for HIV-exposed children poses emotional and physical challenges for caregivers, necessitating support from health professionals and peer groups. Nurses play essential roles in improving caregiver well-being and supporting optimal growth and development in HIV-exposed children under five by designing intervention programs. Furthermore, to enhance home-based HIV care in Indonesia, the government must implement social interventions that target families with limited resources.

Examining the Relationship Between HIV-Related Stigma and the Health and Wellbeing of Children and Adolescents Living with HIV: A Systematic Review

Human immunodeficiency virus (HIV) affects millions of people globally. The associated stigma remains a challenge for individuals living with HIV and children and adolescents face the additional challenge of withstanding the peer, pubertal and identity challenges associated with growing up. The current systematic review aimed to define and explore the major stigma-related challenges of children and adolescents from their own perspectives. A secondary aim was to identify any challenges distinct to childhood and adolescence. Studies included individuals aged 3 to 18 years who were aware of their status. Fifteen studies met inclusion criteria. Narrative synthesis was conducted on the included studies. Five analytic themes emerged describing major stigma-related challenges: disclosure-related anxiety, medication adherence, feelings of abnormality, mental health issues and social exclusion. Disclosure-related anxiety and feelings of abnormality appeared to be largely confined to the experience of children and adolescents. Many of the themes centred around peer influence, highlighting the need to belong in youth. Results suggest that youth require tailored interventions targeting their age-specific challenges.

HIV-Related Stigma, Social Support, and Symptoms of Mental Health Disorders Among People with HIV Initiating HIV Care in Cameroon

HIV-related stigma has been associated with poor mental health among people with HIV (PWH). Social support is a potentially modifiable factor that may buffer negative mental health sequelae of HIV-related stigma. Little is known about the extent to which the modifying effect of social support differs across mental health disorders. Interviews were conducted with 426 PWH in Cameroon. Log binomial regression analyses were used to estimate the association between high anticipated HIV-related stigma and low social support from family or friends and symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and harmful alcohol use, separately. Anticipated HIV-related stigma was commonly endorsed with ∼80% endorsing at least 1 of 12 stigma-related concerns. In multivariable analyses, high anticipated HIV-related stigma was associated with greater prevalence of symptoms of depression {adjusted prevalence ratio (aPR) 1.6 [95% confidence interval (CI) 1.1-2.2]} and anxiety [aPR 2.0 (95% CI 1.4-2.9)]. Low social support was associated with greater prevalence of symptoms of depression [aPR 1.5 (95% CI 1.1-2.2)], anxiety [aPR 1.7 (95% CI 1.2-2.5)], and PTSD [aPR 1.6 (95% CI 1.0-2.4)]. However, social support did not meaningfully modify the relationship between HIV-related stigma and symptoms of any mental health disorders explored. Anticipated HIV-related stigma was commonly reported among this group of PWH initiating HIV care in Cameroon. Social concerns related to gossip or losing friends were of the greatest concern. Interventions focused on reducing stigma and strengthening support systems may be particularly beneficial and have the potential to improve the mental health of PWH in Cameroon.

Impact of Community Support Workers in Rural Ethiopia on Emotional and Psychosocial Health of Persons Living with HIV: Results of a Three-Year Randomized Community Trial

People living with HIV face multiple psychosocial challenges. In a large, predominantly rural Ethiopian region, 1799 HIV patients new to care were enrolled from 32 sites in a cluster randomized trial using trained community support workers with HIV to provide individual health education, counseling and social support. Participants received annual surveys through 36 months using items drawn from the Centre for Epidemiologic Studies Depression Scale-10, Medical Outcome Study Social Support Survey, and HIV/AIDS Stigma Instrument-PLWA. At 12 months (using linear mixed effects regression models controlling for enrollment site clustering), intervention participants had greater emotional/informational and tangible assistance social support scores, and lower scores assessing depression symptoms and negative self-perception due to HIV status. A significant treatment effect at 36 months was also seen on scores assessing emotional/informational social support, depression symptoms, and internalized stigma. An intervention using peer community support workers with HIV to provide individualized informational and psychological support had a positive impact on the emotional health of people living with HIV who were new to care.(ClinicalTrials.gov protocol ID: 1410S54203, May 19, 2015).

The Relationship Between Intersectional Drug Use and HIV Stigma and HIV Care Engagement Among Women Living with HIV in Ukraine

This study used an intersectional approach to explore the association between enacted and internalized drug use and HIV stigma on HIV care outcomes among HIV-positive women who inject drugs in Ukraine. Surveys were conducted in Kyiv in 2019-2020. Among the 306 respondents, 55% were engaged in HIV care. More than half (52%) of participants not engaged in care reported internalized stigma related to both drug use and HIV status (i.e., intersectional stigma), compared to only 35% of those who were engaged in HIV care. Among those engaged in care, 36% reported intersectional enacted stigma compared to 44% of those not engaged in care; however, this difference was not statistically significant in the univariable analysis (p = 0.06). In the univariable analysis, participants who reported intersectional internalized stigma had 62% lower odds of being engaged in HIV care (OR 0.38, 95% CI 0.22, 0.65, p < 0.001). In the adjusted model, reported intersectional internalized stigma (aOR 0.52, 95% CI 0.30, 0.92, p = 0.026), reported intersectional enacted stigma (aOR 0.47, 95% CI 0.23, 0.95, p = 0.036), and knowing their HIV status for more than 5-years (aOR 2.29, 95% CI 1.35, 3.87, p = 0.002) were significant predictors of HIV care engagement. These findings indicate that interventions to improve HIV care engagement must address women's experiences of both HIV and drug use stigma and the different mechanisms through which stigma operates.

Nurses' clinical practices reducing the impact of HIV-related stigmatisation in non-HIV-specialised healthcare settings: a protocol for a realist synthesis

INTRODUCTION

Despite tremendous progress in care, people living with HIV (PLHIV) continue to experience HIV-related stigmatisation by nurses in non-HIV-specialised healthcare settings. This has consequences for the health of PLHIV and the spread of the virus. In the province of Quebec (Canada), only four interventions aimed at reducing the impact of HIV-related stigmatisation by nurses have been implemented since the beginning of the HIV pandemic. While mentoring and persuasion could be promising strategies, expression of fears of HIV could have deleterious effects on nurses' attitudes towards PLHIV. In literature reviews on stigma reduction interventions, the contextual elements in which these interventions have been implemented is not considered. In order to develop new interventions, we need to understand how the mechanisms (M) by which interventions (I) interact with contexts (C) produce their outcomes (O).

METHODS AND ANALYSIS

Realist synthesis (RS) was selected to formulate a programme theory that will rely on CIMO configuration to describe (1) nursing practices that may influence stigmatisation experiences by PLHIV in non-HIV-specialised healthcare settings, and (2) interventions that may promote the adoption of such practices by nurses. The RS will draw on the steps recommended by Pawson: clarify the scope of the review; search for evidence; appraise primary studies and extract data; synthesise evidence and draw conclusions. To allow an acute interpretation of the disparities between HIV-related stigmatisation experiences depending on people's serological status, an initial version of the programme theory will be formulated from data gathered from scientific and grey literature, and then consolidated through realist interviews with various stakeholders (PLHIV, nurses, community workers and researchers).

ETHICS AND DISSEMINATION

Ethical approval for realist interviews will be sought following the initial programme theory design. We intend to share the final programme theory with intervention developers via scientific publications and recommendations to community organisations that counter HIV-related stigmatisation.

Internalized HIV-Related Stigma and Neurocognitive Functioning Among Women Living with HIV

The prevalence of HIV-associated neurocognitive impairment persists despite highly effective antiretroviral therapy (ART). In this study we explore the role of internalized stigma, acceptance of negative societal characterizations, and perceptions about people living with HIV (PLWH) on neurocognitive functioning (executive function, learning, memory, attention/working memory, psychomotor speed, fluency, motor skills) in a national cohort of women living with HIV (WLWH) in the United States. We utilized observational data from a multicenter study of WLWH who are mostly African American living in low-resource settings. Neurocognitive function was measured using an eight-test battery. A multiple linear regression model was constructed to investigate the relationship between internalized stigma and overall neurocognitive functioning (mean of all neurocognitive domain standardized T-scores), adjusting for age, education, race, previous neuropsychological battery scores, illicit drug use, viral load, and years on ART. Our analysis revealed that internalized HIV-related stigma is significantly associated with worse performance on individual domain tests and overall neurocognitive performance (B = 0.27, t = 2.50, p = 0.01). This suggests HIV-related internalized stigma may be negatively associated with neurocognitive functioning for WLWH. This finding highlights a specific psychosocial factor associated with poor neurocognitive function that may be targeted to better promote the health of PLWH. Future research on the longitudinal relationship between these variables and the effects of other stigma dimensions on poor neurocognitive function would provide further insights into the pathways explaining the relationship between internalized stigma and neurocognition.

Psychiatric comorbidity and psychosocial stressors among people initiating HIV care in Cameroon

BACKGROUND

Psychiatric comorbidity, the presence of two or more mental health disorders, has been associated with suboptimal HIV treatment outcomes. Little is known about the prevalence of psychiatric comorbidity among people with HIV (PWH) in sub-Saharan Africa.

METHODS

We conducted interviews with PWH initiating HIV care in Cameroon between June 2019 and March 2020. Depression, anxiety, post-traumatic stress disorder (PTSD), and harmful drinking were dichotomized to represent those with and without symptoms of each. Psychiatric comorbidity was defined as having symptoms of two or more disorders assessed. Moderate or severe household hunger, high anticipatory HIV-related stigma, low social support, and high number of potentially traumatic events were hypothesized as correlates of psychiatric comorbidity. Bivariable log binomial regression models were used to estimate unadjusted associations between psychosocial stressors and psychiatric comorbidity.

RESULTS

Among 424 participants interviewed, the prevalence of psychiatric comorbidity was 16%. Among those with symptoms of at least one mental health or substance use disorder (n = 161), the prevalence of psychiatric comorbidity was 42%. The prevalence of psychiatric comorbidity was 33%, 67%, 76%, and 81% among those with symptoms of harmful drinking, depression, anxiety, and PTSD, respectively. Among individuals with symptoms of a mental health or substance use disorder, a high number of potentially traumatic events (prevalence ratio (PR) 1.71 [95% CI 1.21, 2.42]) and high anticipatory HIV-related stigma (PR 1.45 [95% CI 1.01, 2.09]) were associated with greater prevalence of psychiatric comorbidity.

CONCLUSION

Psychiatric comorbidity was common among this group of PWH in Cameroon. The effectiveness and implementation of transdiagnostic or multi-focus mental health treatment approaches in HIV care settings should be examined.

Geographic Differences in Reaching Selected National HIV Strategic Targets Among People With Diagnosed HIV: 16 US States and Puerto Rico, 2017-2020

Objectives. To assess geographic differences in reaching national targets for viral suppression, homelessness, and HIV-related stigma among people with HIV and key factors associated with these targets. Methods. We used data from the Medical Monitoring Project (2017-2020) and the National HIV Surveillance System (2019) to report estimates nationally and for 17 US jurisdictions. Results. Viral suppression (range = 55.3%-74.7%) and estimates for homelessness (range = 3.6%-11.9%) and HIV-related stigma (range for median score = 27.5-34.4) varied widely by jurisdiction. No jurisdiction met any of the national 2025 targets, except for Puerto Rico, which exceeded the target for homelessness (3.6% vs 4.6%). Viral suppression and antiretroviral therapy dose adherence were lowest, and certain social determinants of health (i.e., housing instability, HIV-related stigma, and HIV health care discrimination) were highest in Midwestern states. Conclusions. Jurisdictions have room for improvement in reaching the national 2025 targets for ending the HIV epidemic and in addressing other measures associated with adverse HIV outcomes-especially in the Midwest. Working with local partners will help jurisdictions determine a tailored approach for addressing barriers to meeting national targets. (Am J Public Health. Published online ahead of print June 2, 2022: e1-e9. https://doi.org/10.2105/AJPH.2022.306843).

Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: A qualitative study

Background

HIV-related self-stigma is a significant barrier to HIV management. However, very little research has explored this phenomenon, particularly in sub-Saharan Africa. This study explored the beliefs, experiences, and impacts of HIV self-stigma amongst adolescents and young adults (AYALHIV) in Harare, Zimbabwe to inform future interventions. It aimed to capture the lived experience of self-stigmatization among AYALHIV and its impact on their social context using Corrigan et al (2009) self-stigma framework of ‘awareness’, ‘agreement’, and ‘application’.

Methods

Virtual semi-structured key informant interviews were conducted between June and July 2020 with adolescents and young adults (Female = 8; Male = 8) living with HIV (18–24 years) in Harare, Zimbabwe. We conducted the interviews with a purposive sample of AYALHIV enrolled in Africaid’s ‘Zvandiri’ program which provides HIV support services. Interviews were mainly conducted in English and with three in Shona, the main indigenous language. Audio-recorded qualitative data were transcribed, translated into English (where necessary) and deductively coded using Corrigan et al.’s self-stigma framework. The outbreak of SARS-CoV-2 coincided with the commencement of data collection activities, which impacted on both the sample size and a shift from in-person to virtual interviewing methods.

Results

Sixteen respondents (50% male) took part in the interviews. The mean age of respondents was 22 years. All respondents reported HIV-related self-stigma either occasionally or frequently. Three main themes of self-stigmatizing experiences emerged: disclosure, relationships, and isolation. These themes were then analyzed within the self-stigma development framework by Corrigan et al. (2009) known as ‘the three As’: awareness, agreement, and application of self-stigmatizing thoughts. Respondents’ experiences of self-stigma reportedly led to poor well-being and decreased mental and physical health. Gendered experiences and coping mechanisms of self-stigma were reported. Data suggested that context is key in the way that HIV is understood and how it then impacts the way people living with HIV (PLHIV) live with, and experience, HIV.

Conclusions

HIV-related negative self-perceptions were described by all respondents in this study, associated with self-stigmatizing beliefs that adversely affected respondents’ quality of life. Study findings supported Corrigan et al.’s framework on how to identify self-stigma and was a useful lens through which to understand HIV-related self-stigma among young people in Harare. Study findings highlight the need for interventions targeting PLHIV and AYALHIV to be context relevant if they are to build individual resilience, while working concurrently with socio-political and systemic approaches that challenge attitudes to HIV at the wider societal levels. Finally, the gendered experiences of self-stigma point to the intersecting layers of self-stigma that are likely to be felt by particularly marginalized populations living with HIV and should be further explored.

Intersecting Stigma and HIV/AIDS Community Participation Among Young Chinese Men Who Have Sex with Men Living with HIV

Community participation is vital for the recovery and empowerment of men who have sex with men (MSM) living with HIV. Intersectionality also provides an important lens that inequalities operate in an intersectional manner and pose compound challenges to the lives of minority individuals. However, the association between intersecting stigma toward HIV-positive MSM and their community participation is underexplored. The study drew on a sample of young Chinese MSM living with HIV from a community-based online survey that recruited respondents using nonprobability purposive sampling (n = 1004). Structural equation modeling was performed to investigate the associations among perceived stigma against sexual minorities and people living with HIV, HIV-related self-stigma, and HIV/AIDS community participation. The indirect effect of self-stigma and the statistical interaction between perceived homosexual stigma and perceived HIV-related stigma were further examined. Results show that total direct effect was significant [B (SE) = 0.859 (0.233); confidence interval (95% CI) = 0.402-1.316]. Perceived HIV-related stigma was positively correlated with HIV/AIDS community participation, while HIV-related self-stigma was negatively correlated. The mediating role of HIV-related self-stigma was significant in both types of perceived stigma [total indirect effect: B (SE) = -0.935 (0.175); 95% CI = -1.277 to -0.593]. The interaction effect was also significant and negative [B (SE) = -0.117 (0.056), p < 0.001], showing that perceived homosexual stigma could offset the effect of perceived HIV-related stigma on HIV-related self-stigma. The findings illustrate how intersecting stigma is involved in HIV-related self-stigma and community participation and highlight the importance of applying an intersectionality perspective to investigate stigma toward MSM living with HIV and their community participation.

HIV Stigma Among a National Probability Sample of Adults with Diagnosed HIV-United States, 2018-2019

HIV stigma is a barrier to achieving the goals of the US Ending the HIV Epidemic initiative. We analyzed data from the Medical Monitoring Project (MMP) collected during 6/2018-5/2019 from 4050 US adults with diagnosed HIV. We reported national estimates of HIV stigma and assessed their associations with sociodemographic and clinical characteristics. Disclosure concerns and stigma related to negative public attitudes were common. Stigma was higher among younger age groups, women and transgender people, Black and Hispanic/Latino men and women, and Black and Hispanic/Latino men who have sex with men. Stigma was associated with lower antiretroviral therapy use and adherence, missed HIV care visits, and symptoms of depression or anxiety. The estimates presented provide a benchmark from which the nation can monitor its progress. The findings suggest the need for enhanced stigma-reduction efforts among specific groups and the importance of addressing stigma around disclosure and community attitudes.

Cognitive Functioning and Its Relationship with Self-Stigma in Men with HIV Who Have Sex with Men: The Mediating Role of Health-Related Quality of Life

Introduction

The human immunodeficiency virus (HIV) stills remains a serious public health problem. HIV acquisition has several negative health consequences, such as a cognitive deterioration or health-related quality of life (HRQoL) impairment. Although these negative consequences could be directly related to a significant increase in self-stigma in this population, few previous studies have analysed the possible associations between these variables. This is especially the case in specific groups of people living with HIV, such as men who have sex with men who could be at a greater risk of stigmatisation. The main aim of the present study was to evaluate the association between cognitive functioning, HRQoL and self-stigma in a group of men with HIV who have sex with men.

Methods

The present study was conducted in the Infectious Diseases Unit of the General University Hospital of Alicante (Spain). The final sample was composed of 70 participants who passed the inclusion and exclusion criteria. All were men with HIV who had sex with men and the sample’s mean age was 45 years. Each participant completed questionnaires on HRQoL and HIV self-stigma. Moreover, they completed an online cognitive assessment through the previously validated platform for cognitive evaluation CogniFit, Inc.

Results

The obtained results showed a significant association between memory functioning impairment, lower levels of HRQoL and higher HIV self-stigma scores. Hence, HRQoL, in the mental summary domain, was shown to be a significant mediator in the relationship between low memory performance and higher HIV self-stigma.

Discussion

Neurocognitive impairment could decrease HRQoL in men with HIV who have sex with men, and hence, reinforce the idea widespread in society that having HIV holds serious consequences. This fact, together with the reduced cognitive abilities to fight against their own self-stigma could represent plausible explanations of the obtained results. In this sense, intervention strategies, oriented towards reducing cognitive impairment, such as those based on cognitive training, and other psychological interventions to promote HRQoL could be effective approaches to prevent the negative effects of HIV self-stigma in this population.

Frameworks, measures, and interventions for HIV-related internalised stigma and stigma in healthcare and laws and policies: systematic review protocol

INTRODUCTION

There is strong global commitment to eliminate HIV-related stigma. Wide variation exists in frameworks and measures, and many strategies to prevent, reduce or mitigate stigma have been proposed but critical factors determining success or failure remain elusive.

METHODS AND ANALYSIS

Building on existing knowledge syntheses, we designed a systematic review to identify frameworks, measures and intervention evaluations aiming to address internalised stigma, stigma and discrimination in healthcare, and stigma and discrimination at the legal or policy level. The review addresses four key questions (KQ): KQ1: Which conceptual frameworks have been proposed to assess internal stigma, stigma and discrimination experienced in healthcare settings, and stigma and discrimination entrenched in national laws and policies? KQ2: Which measures of stigma have been proposed and what are their descriptive properties? KQ3: Which interventions have been evaluated that aimed to reduce these types of stigma and discrimination or mitigate their adverse effects and what are the effectiveness and unintended consequences? KQ4: What common 'critical factors for success or failure' can be identified across interventions that have been evaluated? We will search PubMed, PsycINFO, Web of Science, Universal Human Rights Index, HeinOnline, PAIS, HIV Legal Network, CDSR, Campbell Collaboration, PROSPERO and Open Science Framework. Critical appraisal will assess the source, processes and consensus finding for frameworks; COnsensus-based Standards for the selection of health Measurement Instruments criteria for measures; and risk of bias for interventions. Quality of evidence grading will apply . A gap analysis will provide targeted recommendations for future research. We will establish a compendium of frameworks, a comprehensive catalogue of available measures, and a synthesis of intervention characteristics to advance the science of HIV-related stigma.

PROSPERO REGISTRATION NUMBER

CRD42021249348.

Burn self-stigma: A hybrid concept analysis

AIM

As burn self-stigma has not been addressed fully, the purpose of current study is to analyze dimensions of the concept using literature and lived experiences in burn survivors.

METHODS

Using hybrid concept analysis method, we investigated self-stigma in three phases (i.e. theoretical, fieldwork, and final analytical phase). In the first phase we reviewed the literature using PubMed, SCOPUS, Web of Science, Cochrane Library, OVID, SID and Google Scholar. Thirteen semi-structured interviews with burn survivors were conducted during the fieldwork phase. Two extra interviews with health care providers were undertaken for the aim of data triangulation. Textual content analysis and inductive content analysis were used to analyze the data of the first and second phases of this study, respectively. The findings of both phases were combined in the final analytical phase and a comprehensive definition was emerged.

RESULTS

We assigned all our findings into three content areas (i.e. antecedents, properties and consequences), which are dimensions of self-stigma. In final analytical phase antecedent, properties and consequences of the concept were formed in one (society's misconception about burns), three (negative definition of self, emotional responses, and behavioral responses), and three (negative individual effects, negative social effects, and negative familial effects) categories, respectively. Based on these categories and their corresponding subcategories, a comprehensive definition of the concept was presented.

CONCLUSION

Burn self-stigma is a state in which burn survivors experience unfavorable thoughts and feelings about themselves as a result of society's misconceptions about them. They give emotional and behavioral responses that define them in a negative way. In the end, the burn survivor's individual, familial, and social dimensions are significantly impacted.

Internalised HIV-related stigma associated with physical inactivity in people with HIV and AIDS: A cross-sectional study from Uganda

Aim: The aim of the current study was to explore correlations between continuous physical activity (PA) levels and HIV-related stigma and differences in HIV-related stigma between those who meet versus those who do not meet the international PA recommendation of 150 min of PA per week at moderate intensity.Methods: 295 people living with HIV (PLHIV) (median [interquartile range] age = 37.0 [16.0]; 67.8% [n = 200] female) from central Uganda completed the Internalised AIDS-Related Stigma Scale (IA-RSS), Generalised Anxiety Disorder-7 (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), the Alcohol Use Disorders Identification Test (AUDIT) and the Physical Activity Vital Sign (PAVS).Results: There was a significant correlation between the PAVS and IA-RSS scores correcting for GAD-7, PHQ-9 and AUDIT scores (r = -0.15, p = 0.009). The IA-RSS score was also significantly different between those meeting versus not meeting PA guidelines.Conclusions: Our data demonstrate that higher internalised HIV-related stigma is associated with lower levels of physical activity. The current evidence demonstrates the need to explore whether HIV stigma-reduction interventions could improve physical activity participation and consequently physical and mental health outcomes in PLHIV.

New Directions for the Consideration of HIV: Heterogeneity and the Cognition of Time

It has been almost 40 years since HIV emerged in the human population with an alarming impact in 1981, quickly reaching pandemic proportions. Reaching the goal of eradication, or at least ending the pandemic, however, has not been as easy as hoped. To better understand and therefore better address the persistence and often devastating effects of this now chronic disease, the heterogeneity of HIV-in the virus-human and human-human relationships it engages-is parsed in discussions of the groups affected and the multiple factors that drive the diverse effects of the disease, both of which make treatment and prevention of the disease highly challenging. The construct of time cognition is then considered as a heretofore unexplored factor that may inform our understanding of HIV-relevant behaviors.

HIV-AIDS Stigma in Burundi: A Qualitative Descriptive Study

HIV/AIDS stigma is a global issue and a serious problem in African countries. Although prevalence remains high in this region, no detailed study has yet been carried out to determine and characterize this problem in Burundi. Using a qualitative analysis based on an extensive series of 114 interviews, we describe the main characteristics of HIV stigma in the country. The results of our study indicate that the problem of HIV/AIDS stigma is widespread in Burundian society, as all participants in the research reported having experienced some kind of HIV stigma. The seven dimensions of stigma identified in people living with HIV/AIDS (PLWHA) in Burundi are physical violence, verbal violence, marginalization, discrimination, self-stigma, fear and insecurity, and healthcare provider stigma. These dimensions of stigma can be experienced through different manifestations, which have been characterized in this study, revealing that the problem of stigma in PLWHA is still an important issue in Burundi.

Identifying "What Matters Most" to Men in Botswana to Promote Resistance to HIV-Related Stigma

Despite a comprehensive national program of free HIV services, men living with HIV in Botswana participate at lower rates and have worse outcomes than women. Directed content analysis of five focus groups (n = 38) and 50 in-depth interviews with men and women with known and unknown HIV status in Gaborone, Botswana in 2017 used the "what matters most" (WMM) and "structural vulnerability" frameworks to examine how the most valued cultural aspects of manhood interact with HIV-related stigma. WMM for manhood in Botswana included fulfilling male responsibilities by being a capable provider and maintaining social status. Being identified with HIV threatened WMM, which fear of employment discrimination could further exacerbate. Our findings indicate how cultural and structural forces interact to worsen or mitigate HIV-related stigma for urban men in Botswana. These threats to manhood deter HIV testing and treatment, but interventions could capitalize on cultural capabilities for manhood to promote stigma resistance.

Role of Self-Stigma in Pathways from HIV-Related Stigma to Quality of Life Among People Living with HIV

This study examined the relationships between perceived public stigma, experienced stigma, and quality of life in people living with HIV (PLHIV), and whether self-stigma mediates these relationships. Cross-sectional data were analyzed from 1704 PLHIV in care at OLVG hospital in the Netherlands. We measured different types of stigma (perceived public stigma, experienced stigma, and self-stigma), and various quality-of-life outcomes (disclosure concerns, depression, anxiety, sexual problems, sleeping difficulties, self-esteem, general health, and social support). Structural equation modeling was used to test the paths from different types of stigma to quality-of-life outcomes. All direct effects of self-stigma on quality-of-life outcomes were significant. The final mediation model showed that the effects of both perceived public and experienced stigma on quality-of-life outcomes were mediated by self-stigma. These findings highlight the importance of addressing self-stigma in PLHIV, and call for (psychosocial) interventions that reduce the harmful effects of HIV-related stigma.

A Review of the State of the Science of HIV and Stigma: Context, Conceptualization, Measurement, Interventions, Gaps, and Future Priorities

ABSTRACT

Stigma is a fundamental cause of health inequities. As such, stigma is a major barrier to HIV prevention, care, and treatment. This review will examine the concept of stigma, explicating the mechanisms of action of HIV-related stigma while also examining intersectional stigma and structural stigma. Instruments to measure HIV-related stigma and its mechanisms of action, as well as stigma enacted and experienced by HIV health care providers, will also be reviewed. This article will conclude with a review of stigma interventions, gaps in the literature, and priorities for future HIV, intersectional, and structural stigma research.

The impact of food insecurity on HIV outcomes in Senegal, West Africa: a prospective longitudinal study

BACKGROUND

Understanding the impact of food insecurity on HIV outcomes is critical for the development and implementation of effective, evidence-based interventions to address food insecurity and improve the HIV care cascade. We conducted a prospective, longitudinal study to determine the impact of food insecurity on HIV outcomes in Senegal, West Africa.

METHODS

HIV-infected individuals presenting for care and initiation of ART through the Senegalese National AIDS program in Dakar and Ziguinchor were eligible for enrollment. Data were collected using interviews, clinical evaluations, laboratory analyses, and chart review at enrollment, month 6, and month 12. Logistic regression was used to determine the association between food insecurity and HIV outcomes.

RESULTS

Among the 207 participants in this study, 70% were female and the median age was 37 years. The majority (69%) were food insecure at enrollment, 29% were severely food insecure, and 38% were undernourished. Nearly a third (32%) had no formal education, 23% practiced agriculture, and 40% owned livestock. The median daily food expenditure per person was $0.58. The median round trip transportation time to clinic was 90 min (IQR 30-240). The median cost of transportation to clinic was $1.74. At month 12, 69% were food insecure, 23% were severely food insecure, and 14% were undernourished. At month 12, 43% had not disclosed their HIV status; food insecurity was associated with non-disclosure of HIV-status due to fear of stigmatization and feelings of shame. Severe food insecurity was a strong predictor of loss to follow-up (OR 3.13 [1.08-9.06]) and persistent severe food insecurity was associated with virologic failure (OR 5.14 [1.01-26.29]) and poor adherence to ART 8.00 [1.11-57.57]. Poor nutritional status was associated with poor immunologic recovery (OR 4.24 [1.56-11.47]), virologic failure (OR 3.39 [1.13-10.21]), and death (OR 3.35 [1.40-8.03]).

CONCLUSION

Severity and duration of food insecurity are important factors in understanding the relationship between food insecurity and HIV outcomes. Our findings highlight the importance of nutritional status, socioeconomic opportunity, and self-stigmatization in the complex pathway between food insecurity and HIV outcomes. Interdisciplinary, multisectoral efforts are needed to develop and implement effective interventions to address food insecurity among people living with HIV.