The Association of Perceived, Internalized, and Enacted HIV Stigma With Medication Adherence, Barriers to Adherence, and Mental Health Among Young People Living With HIV in Zambia

Cancer, HIV, and stigma: a portfolio analysis of grants funded by the National Cancer Institute

PURPOSE

People with HIV (PWH) are at higher risk of cancer compared to the general population and experience worse cancer outcomes compared to cancer patients without HIV. One contributing factor to these outcomes is stigma, a social phenomenon that manifests across both HIV and cancer and compounds among those with a dual diagnosis. To assess the state of research, we conducted a portfolio analysis of National Cancer Institute (NCI)-funded extramural grants on this topic.

METHODS

A keyword search identified 47 potentially relevant awards funded between Fiscal Years 2014-2024. Sixteen awards (8 research awards; 8 grant supplements) met inclusion criteria and were further double-coded for key study characteristics.

RESULTS

Funded awards most frequently considered the prevention (n = 6) and treatment (n = 8) phases of the cancer control continuum, with few focusing on other phases of the continuum. Study samples were racially heterogeneous and often socioeconomically challenged, but no grants focused on other high-risk populations such as individuals with disabilities. Stigma was most often assessed as a predictor (n = 10) and measured at the individual level (n = 16). Seven awards assessed both HIV and cancer stigma, but these constructs were usually assessed independently. Only three grants included an intervention component addressing stigma.

CONCLUSION

NCI-supported research on stigma in the context of HIV and cancer has been limited over the past decade. Results point to opportunities for enhancing extramural research in this area, including developing and testing stigma reduction interventions, expanding research across the cancer control continuum, and focusing on all affected populations.

Patient experiences and contextual appropriateness of universal screening for depression and suicide risk in HIV care: a qualitative study in Tanzania

Introduction

Depression and suicidal thoughts and behaviour are remarkably common among people living with HIV worldwide, leading to a higher burden of disease, poor HIV care engagement, and death. Suicidal behaviour is criminalized in 20 countries worldwide, including Tanzania, where context-appropriate interventions are lacking.

Methods

We describe the experiences of patients who were screened for depression and suicidal ideation by HIV clinic nurses, and how the socio-cultural context influences these experiences. This screening was the initial procedure in a randomized controlled clinical trial and parent study aimed at reducing suicide and depression and improving HIV care engagement in Kilimanjaro, Tanzania. We conducted in-depth interviews (IDIs) with 20 people living with HIV. Interviews were held 3 months post-enrollment of participants. Data was collected from July to November 2023. We referred to a brief screener developed for the trial, combining the PHQ-2 for depression and one question on suicidal ideation. IDIs focused on the experiences and appropriateness of being screened for depression and suicidal ideation, factors influencing these challenges, and opinions on the illegality of suicidal behaviour in Tanzania. Data was analyzed using Nvivo 14. Thematic analysis approach was utilized to identify, review and, label codes. Differences were resolved by the first three and final authors.

Results

Our findings revealed high appreciation for the screening and occasional initial discomfort. Stigma, misinformation, and poverty contributed to mental health challenges. Patients favoured abolishment of laws against suicide due to their hindering support-seeking and impracticality for individuals in mental health crises.

Discussion

In a mental health resource-limited setting, these findings highlight the need for targeted and integrated non-specialist screenings and interventions and outsourcing HIV and mental health support beyond healthcare facilities. Further research is needed to assess the sustainability of screening.

Empowerment through knowledge: Qualitative perceptions of 'undetectable equals Untransmittable' among people living with HIV and tuberculosis in South Africa

INTRODUCTION

Undetectable equals untransmittable (U=U) is an education campaign promoting science that people living with human immunodeficiency virus (HIV) who maintain an undetectable viral load cannot transmit HIV to others. Researchers theorize that undetectable equals untransmittable messaging will decrease HIV stigma by reducing fears of HIV transmission and providing evidence to dismantle discriminatory policies. However, little is known about how people with HIV in South Africa interpret the results of their viral load tests, undetectable equals untransmittable messaging, or its impact on stigma.

METHODS

This qualitative study explored knowledge and interpretation of viral suppression, and undetectable equals untransmittable among people with HIV and rifampicin-resistant tuberculosis in South Africa. We further explored whether undetectable equals untransmittable messaging influences HIV-related stigma. Thirty participants were recruited for serial qualitative interviews, conducted at baseline, 3-month, and 6-month visits. A multi-national team used reflexive thematic analysis to develop and interpret code relationships.

RESULTS

All participants were Black African, age on average was 36 years, 63.3 % were male, and half were undetectable at baseline with a median 6.2 years since HIV diagnosis. Four themes were identified that built on one another over time, (1) limited knowledge of viral suppression and undetectable equals untransmittable; (2) perceived lack of clinical integration of viral suppression and undetectable equals untransmittable; (3) Changing perceptions of viral suppression and application to individual health; and (4) endorsement of undetectable equals untransmittable and activation towards health partnership. Most participants had not heard of viral suppression or undetectable equals untransmittable at the initial interview. There was limited integration of viral suppression or undetectable equals untransmittable into clinic visits fueling a perception that viral suppression was solely a tool for verification of adherence. Over time, participants came to understand the significance of viral suppression and undetectable equals untransmittable, which empowered participants to take a more active role in their HIV management and request changes from the healthcare system.

CONCLUSIONS

Participants found optimism and empowerment through individualized HIV education even though undetectable equals untransmittable messaging had little impact on stigma. There are structural barriers in the South African healthcare system that limit access to tailored health education. By leveraging community health workers and enrolled nurses, HIV clinics can improve education access without overtaxing a resource strained healthcare system. These results identify a variety of opportunities for health system strengthening that build on the global momentum of undetectable equals untransmittable.

Antipsychotic medication non-adherence and its determinants among out-patients with schizophrenia

Introduction

While antipsychotics are key requirement in acute and long-term management of schizophrenia, medication adherence remains a major unmet need in its care. This paper assessed the prevalence of oral antipsychotic non-adherence among outpatients with schizophrenia and its associated clinico-demographic factors.

Method

Three hundred and ten adult outpatients (18-64 years of age) were cross-sectionally interviewed after being diagnosed of schizophrenia using ICD-10 criteria, and the diagnosis confirmed with the Mini International Neuropsychiatric Interview (MINI). The socio-demographic questionnaire, Morisky Medication Adherence scale (MMAS-8), Brief Psychiatric Rating Scale (BPRS), Liverpool University Neuroleptic Side Effects Scale (LUNSERS), Drug Attitude Inventory (DAI-10), Scale to Assess Unawareness of Mental Disorders (SUMD) were used to obtain participants' demographic profile, level of medication adherence, illness severity, attitude towards antipsychotics, and level of insight respectively.

Results

At least one in every two outpatients with schizophrenia (n=158; 51.0%) did not adhere to their antipsychotics as prescribed. The independent risk factors for poor oral antipsychotic adherence were illness severity (p= 0.001; AOR 1.13), psychoactive substance use (p= 0.009; AOR 1.87), young age (p= 0.014; AOR 2.09), perceived poor social support (p= 0.025; AOR 3.58), use of first generation antipsychotics alone (p= 0.006; AOR 17.99), use of second generation antipsychotics alone (p= 0.02; AOR 29.36), and awareness of symptoms (p= 0.025; AOR 1.18).

Conclusion

The high rate of poor medication adherence should necessitate much emphasis on the highlighted modifiable risk factors and the need for continuous adherence assessments and education in clinical practice.

'The tablets make a certain noise': uncovering barriers and enablers related to providing PMTCT services to adolescents and young women living with HIV in Zimbabwe

BACKGROUND

Zimbabwe antenatal HIV prevalence rate is 16.1%. HIV-positive pregnant adolescent girls and young women (AYW) are at high risk to experience perinatal mental health challenges, attributed to a combination of factors including HIV status, stigma and perinatal depression. Perinatal depression and stigma among AYW is understudied in Zimbabwe and may affect short- and long-term health of HIV positive mothers and their children, and can impact treatment adherence.

METHODS

Qualitative data was gathered from four focus group discussions with (2 urban and 2 rural) PMTCT providers (N = 17). Focus group discussions were also conducted among AYW clients (N = 20) from two clinics in Mashonaland East.

RESULTS

Qualitative analyses identified patterns related to: (1) drop out and loss to follow up, (2) retention and adherence, (3) recurring feelings of internalized stigma; and (4) acceptability of potential MH interventions. MH services are not available and AYW have limited access to adherence counseling (1-2 times at onset). Psychological support was not available at either clinic, despite both providers and clients perceiving high rates of stigma, discrimination, and challenges with disclosure. Challenges related to long waits for ART distribution and gaps in disclosure support emerged as barriers. Providers noted that AYW present as anxious (non-diagnosed), and attribute depression to those clients who are lost to follow up, stating lack of time to screen for MH related issues or actively refer them for services. Challenges related to the ability to provide strong advice and support for disclosure also emerged among providers.

CONCLUSIONS

This study can contribute to policy and practice recommendations to better integrate MH into HIV services and develop person-centered service models for HIV positive AYW. HIGHLIGHTSPerinatal adolescents and young women (AYW) living with HIV have gaps in retention and care in the current Zimbabwe PMTCT service model.Mental health stigma must be addressed to integrate mental health into HIV services.HIV providers are aware of the need to provide mental health support to reduce loss to follow-up.Mental health screening and referrals for services are not part of standard care for perinatal HIV positive AYW in Zimbabwe.Linkages between disclosure and AYW mental health was identified as a challenge by HIV providers.Context responsive interventions can support integration of mental health screening, services, and referrals.

HIV Stigma, Health, and Violence: A Longitudinal Study among Adolescent Boys with HIV in Soweto, South Africa

There are over 1.4 million adolescents living with HIV in sub-Saharan Africa, the majority of whom acquired the virus through perinatal transmission (PHIV). HIV stigma is particularly high among adolescents living with HIV and is associated with several outcomes that worsen health and increase the risk of onward HIV transmission. We tested associations between internalized HIV stigma and four of these outcomes over a one-year period among a sample of adolescent boys living with PHIV in Soweto, South Africa. Participants (N = 241) answered questions about internalized HIV stigma at baseline. They completed weekly mobile surveys over the following year to answer questions about their experiences with depression, binge drinking, medication adherence, and violence victimization. Using generalized linear mixed models, we found that baseline internalized HIV stigma was associated with increased odds of depression (OR 1.74), alcohol misuse (OR 2.09), and violence victimization (OR 1.44) and decreased odds of medication adherence (OR 0.60) over the course of a year. These outcomes negatively impact the health and wellbeing of adolescents living with PHIV and increase their risk of transmitting HIV to their partners in the future. Our findings provide novel, longitudinal evidence for the deleterious effects of HIV stigma. To improve health outcomes for adolescents with PHIV, it will be crucial to develop effective HIV stigma reduction interventions that address specific developmental, gendered, and cultural experiences.

Adherence to antiretroviral therapy among cisgender gay, bisexual and other men who have sex with men in Brazil: Evaluating the role of HIV-related stigma dimensions

BACKGROUND

In Brazil, ~35% of people living with HIV (PLHIV) have poor adherence to antiretroviral therapy (ART). HIV-related stigma is associated with worst continuum of care outcomes, however evidence from Brazil is scarce. We explored pathways between HIV-related stigma dimensions and ART adherence among Brazilian cisgender gay, bisexual and other men who have sex with men (MSM) living with HIV.

METHODS

A sample of MSM ≥18 years was recruited online between February/March 2020 through advertisements on Hornet, a location-based dating app. Validated scales were used to assess ART adherence and HIV-related stigma. Indirect and direct pathways between HIV-related stigma dimensions and ART adherence were estimated using structural equation models while considering socio-demographic and substance use related variables. Models were estimated using mean- and variance-adjusted weighted least squares, and goodness of fit indices were calculated.

FINDINGS

Among 1,719 MSM living with HIV who reported starting ART, 70% were adherent. There was evidence of indirect effects of concerns about public attitudes (standardized coefficient (SC) = -0.095, 95% confidence interval (95%CI) = -0.172 - -0.017) and personalized HIV-stigma (SC = -0.022, 95%CI = -0.043 - -0.001) on ART adherence mediated through negative self-image. Personalized HIV stigma and concerns about public attitudes were both positively associated with negative self-image (SC = 0.129, 95%CI = 0.066-0.193; SC = 0.549, 95%CI = 0.494-0.603), and concerns about public attitudes was associated with HIV disclosure concerns (SC = 0.522, 95%CI = 0.463-0.581). However, the direct paths from personalized HIV stigma and concerns about public attitudes to ART adherence were not significant.

INTERPRETATION

Our research underscores the critical need for multifaceted interventions to eliminate HIV-related stigma at both individual and societal levels. At the individual level, psychotherapeutic interventions to improve self-image might helpful. Additionally, public policy should aim to dismantle structural stigma with awareness campaigns on various media channels, integration of anti-stigma curriculum into schools, and training for professionals.

"What if I got rejected by the girl? I would rather stop the pills": barriers and facilitators of adherence to antiretroviral therapy for emerging adults aged 18-29 living with HIV in Zimbabwe

Emerging adults aged 18-29 have high rates of viral non-suppression, and poorer adherence to ART when compared to older adults. Semi-structured interviews were conducted with 24 emerging adults in Zimbabwe who had a recent history of viral non-suppression, to explore barriers and facilitators of adherence to ART. Interviews were coded using inductive thematic analysis. The mean age of participants was 23, 65% were male, and 79% reported acquiring HIV at birth. Twelve barriers to adherence were identified. Hiding HIV status due to the possible negative consequences of disclosure had a significant impact on adherence to ART. This was particularly important for emerging adults navigating starting intimate relationships. Being away from home, poverty, poor mental health, isolation, significant life events, alcohol, health systems barriers, and stigma were reported as barriers to adherence. Support from peers and family after disclosure of HIV status, phone-based reminders, problem-solving strategies to adhere, knowing others living with HIV, acted as facilitators to adherence to ART. Beliefs about medicines and relationships with health care providers acted as both barriers and facilitators to adherence. Interventions to reduce stigma, foster peer support, and therapy for common mental disorders could facilitate emerging adults aged 18-29 to adhere to ART.

The link between anticipated and internalized stigma and depression: A systematic review

Stigmatized groups may experience psychological distress. Yet, some studies show no significant relation between stigma and mental health outcomes. This systematic review investigates the link between anticipated and internalized stigma, and one mental health outcome, depression. We aimed to (1) determine whether anticipated and internalized stigma predict levels of depression, and (2) review the quality of evidence for this link. We searched PsycInfo, PubMed and EMBASE databases. Eighty-three studies (N = 34,705) met our inclusion criteria, across five stigma categories: Sexual and gender minorities; HIV/AIDS; Illness or disability-related (non-HIV); Weight, and Other. We reviewed evidence within each category and study design and developed a narrative synthesis. Sixty studies (72.3%) supported the proposed link, which varied across categories from 53.6% to 100%. Using the NIH quality assessment tool, most studies were of fair quality. Most cross-sectional studies (76.7%) straightforwardly supported the positive relation between internalized and/or anticipated stigma and depression, while only 40% of longitudinal studies did. Implications for the study of stigma and mental health outcomes are discussed.

"I would prefer to be dead than to live this way": Lived experiences of stigma and discrimination against khwaja sira in Swat, Pakistan

Due to their identification as third gender people, khwaja sira have historically been subjected to experiences of social marginalization. However, the extant literature has not fully explored the lived experiences of stigma and discrimination against khwaja sira in the Swat Valley of Khyber Pakhtunkhwa, Pakistan. To address this gap, we conducted 45 interviews with khwaja sira in Mingora, Swat, Khyber Pakhtunkhwa to better understand their experiences of gender-nonconformity stigma and discrimination in various social contexts, including within their families, in accessing health care, and within education and work contexts. Applying Minority Stress Theory and utilizing thematic content analysis, the present study identified three dimensions of gender-nonconformity stigma: (1) internalized stigma, namely feelings of shame and embarrassment; (2) perceived stigma, namely opinions others had of khwaja sira regarding lack of employability or engagement in sex work; and (3) enacted stigma, namely exclusion from families, in educational settings, in religious spaces, and in healthcare settings. Findings should inform future social intervention and community practice engagements with khwaja sira communities in Pakistan.

Associations Between Internalized and Anticipated HIV Stigma and Depression Symptoms Among People Living with HIV in China: A four-wave Longitudinal Model

Previous research has documented that HIV-related stigma (e.g., internalized and anticipated stigma) is detrimental to the mental health of people living with HIV (PLWH). However, longitudinal data on the bidirectional relationship between HIV-related stigma and depression symptoms are limited. The purpose of this study was to examine the bidirectional association among internalized and anticipated HIV stigma and depression symptoms among Chinese PLWH. A four-wave longitudinal design (6 months intervals) was employed among 1,111 Chinese PLWH (Mage = 38.58, SD = 9.16, age range: 18-60 years; 64.1% men). The bidirectional model was examined using a random-intercept cross-lagged panel model (RI-CLPM), which evaluated the within- and between-person effects of study variables. At the within-person level, results indicated that depression symptoms at T2 mediated the linkage between internalized HIV stigma at T1 and anticipated HIV stigma at T3, and that anticipated HIV stigma at both T2 and T3 mediated the relationship between depression symptoms at the previous time point and internalized HIV stigma at the subsequent time point. Furthermore, a bidirectional association was found between anticipated HIV stigma and depression symptoms across four waves. At the between-person level, internalized and anticipated HIV stigma were significantly associated with depression symptoms. This study highlights the complex interplay between different forms of HIV-related stigma and mental health problems among PLWH and underscores the importance of considering the bidirectional relationship between the development of psychopathology and stigmatization process in clinical practice.

Structural, Familial, and Psychosocial Factors Affecting Long-Term Antiretroviral Treatment Adherence amongst Adolescents Living with Perinatally Acquired HIV in Limpopo, South Africa

After more than two decades of the expansion of antiretroviral treatment (ART) in adolescents living with perinatal HIV (APHIV) in sub-Saharan Africa, there is still poorly sustained long-term adherence to ART due to multifactorial factors with the consequence of increased mortality and morbidity. There are little data available on the familial and structural factors which affect sustenance to long-term adherence to ART. A qualitative exploratory design was used to conduct in-depth interviews with 21 APHIV attending HIV care and management in the rural health facilities of Vhembe district in Limpopo Province, South Africa. Transcripts were translated verbatim into English, and data were analyzed using Tesch's eight steps of qualitative data analysis. The sample consisted of APHIV 10-19 years old who were aware of their HIV status, and all had received ART for more than 5 years. They lived in extended, disrupted, grandparent- and child-headed households. They experienced food insecurities due to poverty or orphanhood, as well as living in disrupted households, which deterred them from long-term adherence. In addition, dependency on social support grants to sustain their livelihoods affected long-term adherence. APHIV had challenges with structural factors such as inconsistent clinic attendance, clashes between school activities and clinic appointments, and the lack of transport fare to the clinic, which affected adherence. Although APHIV were on one-pill fixed-dose ART, they were not able to sustain long-term adherence due to various familial, structural, and psychosocial challenges. In addition to institution-based interventions, there is a need for family, community-based, and multi-sectorial interventions to support long-term ART adherence among APHIV.

Adherence to antiretroviral therapy among HIV patients in Ghana: A systematic review and meta-analysis

Maintaining a high level of adherence to antiretroviral therapy (ART) is critical to limiting rapid viral replication, drug resistance, and viral transmission. However, ART adherence remains a major challenge in HIV/AIDS treatment success. This systematic review and meta-analysis was aimed to synthesize available evidence on adherence to ART among HIV/AIDS patients in Ghana.This review followed the preferred reporting item for systematic review and meta-analysis (PRISMA) criteria. A comprehensive literature search was done using five online databases (PubMed, Google Scholar, Medline, Africa Index Medicus, and Willey Online Library) from 25th- 30th April 2023 to identify potential studies. In addition, references of related articles were manually searched to further identify relevant studies. Search records were managed in Endnote library where duplicates were removed prior to screening. Studies were eligible for inclusion if they were conducted in Ghana, designed as an observational or experimental study, and explicitly measured adherence to ART, either as a primary or secondary outcome. Studies were excluded if the proportion or prevalence of adherence to ART was not reported.A total number of 126 potential studies were identified from the literature search. Of these, 14 met the inclusion criteria and were included in the Meta-analysis. The studies involved a total number of 4,436 participants. The pooled estimate of adherence to ART was 70% (CI: 58-81%). In subgroup analysis, adolescents and young adults had a lower adherence rate (66%, CI: 46-84%) compared with adults (70%; CI: 58-81%). Publication bias was not observed among studies. The pooled estimate of optimal adherence to ART among HIV patients in Ghana was lower than is recommended (≥95%) to achieve viral suppression. Adherence was lower among young persons living with HIV/AIDS. To achieve the United Nation's Sustainable development goals and the UNAIDS "95-95-95" targets, there is a need to focus on improving adherence interventions among persons living with HIV/AIDS, especially among the younger cohort.

Community Perceptions of HIV Stigma, Discriminatory Attitudes, and Disclosure Concerns: A Health Facility-Based Study in Selected Health Districts of South Africa

Research data about HIV stigma perceptions and discriminatory attitudes among the general population are limited. Furthermore, the willingness of HIV-negative individuals to engage with HIV prevention and disclosure interventions has not been established in South Africa. The study investigated community perceptions of stigma as well as discriminatory attitudes towards HIV disclosure to understand if and how these perceptions might influence the uptake of disclosure interventions. This facility-based study used a validated questionnaire to measure the four constructs of HIV stigma among 670 adults recruited from health districts of two provinces of South Africa. Of these, 72% were female, 87% had ever been tested for HIV, and 31% knew someone who has HIV. Stigma towards people living with HIV (PLHIV) is widespread in the general population. A high proportion (75%) endorsed disclosure concerns, 75% perceived stigma to be common, and 56% endorsed negative statements indicating perceived stigma in communities. Fear, moral and social judgement, and rejection underlined their perceptions about PLHIV. Almost half (45.7%) were unwilling to care for family members sick with AIDS, suggesting negative distancing reactions and discriminatory attitudes towards PLHIV. The widespread discriminatory attitudes and the perceived stigma that is evident in the general population might heighten the disclosure concerns endorsed, promote non-disclosure, and increase HIV transmission. To design interventions, it is crucial to be cognisant of disclosure concerns, discriminatory attitudes, and perceived stigma evident in communities. Thus, the findings underscore the need to increase efforts to challenge and reduce community drivers of negative discriminatory attitudes and perceived stigma.

"When they are all grown, I will tell them": Experience and perceptions of parental self-disclosure of HIV status to children in Nairobi, Kenya

BACKGROUND

There is mixed evidence on the influence of self-disclosure of one's HIV status on mental health, health behaviours and clinical outcomes. We studied the patterns of self-disclosure among parents living with HIV, and factors that influence parental disclosure.

METHODS

This mixed-methods study was among adults in HIV care participating in a study assessing the uptake of pediatric index-case testing. They completed a survey to provide demographic and HIV-related health information, and assess self-disclosure to partners, children and others. We ran generalized linear models to determine factors associated with disclosure and reported prevalence ratios (PR). Eighteen participants also participated in in-depth interviews to explore perceived barriers and facilitators of self-disclosure to one's child. A content analysis approach was used to analyze interview transcripts.

RESULTS

Of 493 caregivers, 238 (48%) had a child ≥ 6 years old who could potentially be disclosed to about their parent's HIV status. Of 238 participants, 205 (86%) were female, median age was 35 years, and 132 (55%) were in a stable relationship. Among those in a stable relationship, 96 (73%) knew their partner's HIV status, with 79 (60%) reporting that their partner was living with HIV. Caregivers had known their HIV status for a median 2 years, and the median age of their oldest child was 11 years old. Older caregiver age and older first born child's age were each associated with 10% higher likelihood of having disclosed to a child (PR: 1.10 [1.06-1.13] and PR: 1.10 [1.06-1.15], per year of age, respectively). The child's age or perceived maturity and fear of causing anxiety to the child inhibited disclosure. Child's sexual activity was a motivator for disclosure, as well as the belief that disclosing was the "right thing to do". Caregivers advocated for peer and counseling support to gain insight on appropriate ways to disclose their status.

CONCLUSIONS

Child's age is a key consideration for parents to disclose their own HIV status to their children. While parents were open to disclosing their HIV status to their children, there is a need to address barriers including anticipated stigma, and fear that disclosure will cause distress to their children.