Stigma and rejection: living with AIDS in villages in southern Thailand

The Trouble of Stigma in the Age of Datafication: Screening for Mental Health Issues in a Refugee Camp in Jordan

Drawing on ethnographic fieldwork in a refugee camp in Jordan, this article investigates how datafication through digital screening technologies helps shape mental health issues in the face of widespread uneasiness about the subject, especially among the intended beneficiaries. We argue that the refugees and their health care providers face a dilemma: on the one hand, the desire to make mental health issues visible and clinically actionable through datafication and, on the other hand, the wish to keep mental health issues out of public view to avoid potential stigma.

Experiences of Thai-Muslim patients regarding inconsistent antiretroviral therapy adherence: An exploratory descriptive qualitative study

Background

Antiretroviral therapy (ART) has played a crucial role in saving countless lives of patients with HIV/AIDS across the world. However, despite its effectiveness, ART adherence still falls short globally, and non-adherence remains the primary cause of treatment failure. In the rural areas of southern Thailand, where the population is predominantly conservative Muslims, there has been an observed increase in ART non-adherence.

Objective

This study aimed to explore experiences of inconsistent ART adherence among Thai-Muslim patients with HIV/AIDS (PWHAs) in southern Thailand. In addition, the perspectives of healthcare providers were also sought.

Methods

Data were collected by conducting semi-structured in-depth interviews with ten Thai-Muslim PWHAs and five healthcare providers at a Voluntary Counseling-and-Testing Clinic. A content analysis approach was utilized to analyze the data.

Results

Inconsistent ART adherence was reported. Religion/spiritual imperatives, forgetfulness, inadequate knowledge (of drug side effects and drug regime), misunderstandings (about being symptom-free and feeling well), boredom from long-term drug-taking regimes, as well as poor transportation and lack of family support (arising from non-disclosure of one's HIV-serostatus due to HIV stigma) were emergent themes derived from the interviews with Thai-Muslim PWHAs. The healthcare providers' interview data revealed their need for the integration of Islamic beliefs to provide better care.

Conclusion

It is essential for healthcare teams to work collaboratively with patients' religious beliefs to enhance ART adherence. Clinical nurses can contribute to the promotion of HIV-care services by integrating Islamic beliefs and Muslim culture into their practice, thus increasing patients' knowledge and motivation for ART adherence. This could entail utilizing Islamic prayer rituals as drug reminders, elaborating on Islamic moral beliefs concerning sickness and healing, and integrating the cultural imperatives of self-care in the Muslim community into ongoing care delivery. Cross-cultural nursing education and specialized training in HIV care should incorporate knowledge about Islamic and Muslim cultural beliefs.

We Are Still Here: Living with HIV in the UK

In this article we highlight a number of the ongoing challenges faced by people living with HIV in the UK today (2021). Based on in-depth interviews with 23 respondents drawn from a range of ages, backgrounds and walks of life, we offer an insight into deeply personal experiences of what it means to have HIV. We demonstrate the degree to which, 40 years on from the formal emergence of the HIV pandemic, stigma and related structural violence remain both extremely present and extraordinarily debilitating. In essence, social responses to HIV remain mired in a past age.

Biocultural perspectives of infectious diseases and demographic evolution: Tuberculosis and its comorbidities through history

Anthropologists recognize the importance of conceptualizing health in the context of the mutually evolving nature of biology and culture through the biocultural approach, but biocultural anthropological perspectives of infectious diseases and their impacts on humans (and vice versa) through time are relatively underrepresented. Tuberculosis (TB) has been a constant companion of humans for thousands of years and has heavily influenced population health in almost every phase of cultural and demographic evolution. TB in human populations has been dramatically influenced by behavior, demographic and epidemiological shifts, and other comorbidities through history. This paper critically discusses TB and some of its major comorbidities through history within a biocultural framework to show how transitions in human demography and culture affected the disease-scape of TB. In doing so, I address the potential synthesis of biocultural and epidemiological transition theory to better comprehend the mutual evolution of infectious diseases and humans.

Pandemics, past and present: The role of biological anthropology in interdisciplinary pandemic studies

Biological anthropologists are ideally suited for the study of pandemics given their strengths in human biology, health, culture, and behavior, yet pandemics have historically not been a major focus of research. The COVID‐19 pandemic has reinforced the need to understand pandemic causes and unequal consequences at multiple levels. Insights from past pandemics can strengthen the knowledge base and inform the study of current and future pandemics through an anthropological lens. In this paper, we discuss the distinctive social and epidemiological features of pandemics, as well as the ways in which biological anthropologists have previously studied infectious diseases, epidemics, and pandemics. We then review interdisciplinary research on three pandemics–1918 influenza, 2009 influenza, and COVID‐19–focusing on persistent social inequalities in morbidity and mortality related to sex and gender; race, ethnicity, and Indigeneity; and pre‐existing health and disability. Following this review of the current state of pandemic research on these topics, we conclude with a discussion of ways biological anthropologists can contribute to this field moving forward. Biological anthropologists can add rich historical and cross‐cultural depth to the study of pandemics, provide insights into the biosocial complexities of pandemics using the theory of syndemics, investigate the social and health impacts of stress and stigma, and address important methodological and ethical issues. As COVID‐19 is unlikely to be the last global pandemic, stronger involvement of biological anthropology in pandemic studies and public health policy and research is vital.

Increased Work Experience Associated with Less Stigmatizing Attitudes towards People Living with HIV among Thai Healthcare Personnel

HIV-related stigma in health facilities has been suggested as a primary target for HIV-related stigma reduction. The objective of this study was to describe negative attitudes among Thai healthcare personnel (HCP) toward PLHIV. This nationwide probability sampled survey was conducted in 2019 in 12 provinces in Thailand and Bangkok, the capital. Participants were considered to have stigmatizing attitudes toward PLHIV if they had a stigmatizing view in response to at least one of the four questions. Eighty-two percent of the 3056 respondents had at least one stigmatizing attitude. Younger HCP, ages < 30 (AOR = 1.60; 95%CI: 1.18–2.18) and 30–39 (AOR = 1.60; 95%CI: 1.21–2.12) were more likely to have stigmatizing attitudes towards PLHIV compared to those aged 50 and older. Being support staff, support-clinical (AOR = 1.89; 95%CI: 1.44–2.49) and support-nonclinical (AOR = 1.71; 95%CI: 1.24–2.36) as opposed to professional staff also increased the likelihood of having stigmatizing attitudes. Stigma was also more likely to be present in HCPs who did not work at HIV-focused clinics (AOR = 1.97; 95%CI: 1.57–2.48). HCP who had more work experience, especially related to PLHIV care, were less likely to have stigmatizing attitudes. These personnel could be good peer educators or role models for a stigma reduction campaign within their healthcare facilities.

Determinants and effects or consequences of internal HIV-related stigma among people living with HIV in Morocco

BACKGROUND

HIV-related stigma and discrimination constitute a barrier to different intervention programs. Unlike external stigma, internal stigma is not well explored in in the Middle East and North African countries, while grasping this particular form of stigma is essential to limit its effects. The present study aims to measure internal stigma effects and to identify factors associated with this kind of stigma not yet documented among people living with HIV (PLHIV) in Morocco.

METHODS

The PLHIV Stigma Index questionnaire (adapted and translated into French and Moroccan Arabic dialect "darija") was used to collect information regarding the stigma and discrimination experienced by PLHIV across 8 cities in Morocco (September-October 2016). A randomly drawn cluster of 10 PLHIV, consisting of 5 men and 5 women, was drawn at each participating medical care center to achieve a nationally representative sample of PLHIV. Fifteen interviewers living with HIV and five supervisors were selected and trained to administer the questionnaire. An internal stigma score (range: 0-7), was calculated based on seven negative feelings/ beliefs. Negative binomial regression was used to identify characteristics associated with the internal stigma score.

RESULTS

Among 626 PLHIV, internal stigma was reported by 88.2%. The median [IQR] internal stigma score was 4 [2-5]. Regarding internal stigma, 51% avoided going to the local clinic when needed and 44% chose not to attend social gatherings. Belonging to at least one key population (aIRR [95%CI] = 1.15 [1.03; 1.28]), experiencing discriminatory reactions from family following HIV status disclosure (1.28 [1.11; 1.49]), avoiding HIV services for fear of stigmatization by staff (1.16 [1.05; 1.28]) and being denied health services because of HIV status (1.16 [1.03;1.32]), are among the factors significantly associated with an increase of the internal stigma score.

CONCLUSIONS

Internal stigma is high among Moroccan PLHIV and significantly impacting their life decisions and their healthcare access. Multi-level interventions are needed to address internal stigma experienced by PLHIV in Morocco.

A Qualitative Exploration of Psychosocial Challenges of Perinatally HIV-Infected Adolescents and Families in Bangkok, Thailand

Thailand has the highest HIV prevalence in Asia, with 9,600 HIV+ adolescents and thousands additional younger HIV+ children (World Bank, 2015; UNICEF, 2015). Studies from other settings suggest perinatally HIV-infected (PHIV+) adolescents are at high risk for mental health problems and engagement in risk behaviors that threaten individual and public health. Yet, few studies exist in Thailand, and few evidence-based psychosocial interventions have been developed for and studied in this population, despite great need. The current study qualitatively explored psychosocial issues among Thai PHIV+ adolescents to inform development or adaptation of interventions. Thai and US-based researchers and clinicians conducted two focus group discussions with PHIV+ adolescents aged 12-16 and their adult caregivers, and six in-depth key informant interviews with health/social work providers at a large clinic for PHIV+ youth in Bangkok, Thailand. Data were analyzed thematically using framework analysis. Multiple challenges for PHIV+ youth and caregivers were identified. Adherence to antiretroviral treatment was a significant challenge attributed to lack of adult support, side effects, feeling too well to take medicines, and avoiding acknowledging sickness. Poor child-caregiver communication and conflict was a key concern, explained in part by cultural expectation of obedience and generation gaps. Concerns about societal stigma and discrimination emerged strongly and influenced delay or avoidance of disclosing HIV status to children and others. Respondents identified positive approaches to addressing these issues and highlighted the need for interventions to improve child-caregiver communication and generate peer and community support for PHIV+ youth. Thai PHIV+ adolescents and families experience significant psychosocial challenges, similar to those seen in other contexts. Cultural adaptation of an existing evidence-based clinic-based family group intervention is recommended to rapidly address these needs.

Albinism, stigma, subjectivity and global-local discourses in Tanzania

Societal ideas and explanations of albinism at the local level in Tanzania are conceived in terms of family history, social relations, economic status, moral-religious positions, global-local flows of information and humanitarian actions on behalf of people with the congenital condition. This paper aims to show how the subjectivities of people with albinism in Tanzania are shaped and re-shaped through local moral conceptions as well as globalizing (bio)medical explanations of albinism. An exemplary case study of a 28-year-old woman, plus episodes from the lives of seven other informants with the condition, are analyzed in order to understand, on the one hand, local social relationships between people with albinism and other individuals in family and community settings, and on the other hand, the interconnections between persons with albinism and global humanitarian actors and the broadcast media. When stigma and marginalizing behaviors are perceived by individuals with albinism in Tanzania as impeding their social lives, they employ different coping strategies and discourses to enhance social acceptance.

Perceived Family Support and Antiretroviral Adherence in HIV-Positive Individuals: Results from a Community-Based Positive Living With HIV Study

The purpose of this study was to examine the association between perceived family support, either positive or negative, and adherence to antiretroviral medication regimens among HIV-positive individuals in the Kathmandu Valley, Nepal. We measured past 3-month antiretroviral adherence among 233 HIV-positive individuals, in relation to perceived family support, both positive (in terms of emotional and instrumental support) and negative (in the form of negative interactions), using the 10-item Nepali Family Support and Difficulty Scale. Medium and high levels of perceived emotional support from family were associated with reduced risk of antiretroviral nonadherence, compared with low levels of perceived emotional support (adjusted odds ratio [AOR]  = 0.37, 95% confidence interval [CI] [0.16, 0.88], and AOR  = 0.23, 95% CI [0.08, 0.64], respectively). Conversely, higher levels of felt emotional distance (AOR  = 1.46, 95% CI [1.00, 2.14]) and experienced physical harm (AOR  = 2.04, 95% CI [1.07, 3.91]) were associated with increased risk of nonadherence. The results support the recommendation that service providers need to be aware of the significant role of family support in shaping antiretroviral adherence and to consider ways to strengthen positive family support while minimizing negative family interactions to increase adherence rates.

Homosexuality-related stigma and sexual risk behaviors among men who have sex with men in Hanoi, Vietnam

This article examined the associations between three forms of homosexuality-related stigma (enacted, perceived, and internalized homosexual stigmas) with risky sexual behaviors, and to describe the mechanisms of these associations, among men who have sex with men (MSM) in Hanoi, Vietnam. We used respondent-driven sampling (RDS) to recruit 451 MSM into a cross-sectional study conducted from August 2010 to January 2011. Data were adjusted for recruitment patterns due to the RDS approach; logistic regression and path analyses were performed. Participants were young and single; most had attended at least some college. Nine out of ten participants engaged in sexual behaviors at moderate to high risk levels. Compared to those who had no enacted homosexual stigma, men having low and high levels of enacted homosexual stigma, respectively, were 2.23 times (95 % CI 1.35-3.69) and 2.20 times (95 % CI 1.04-4.76) more likely to engage in high levels of sexual risk behaviors. In addition, there was an indirect effect of perceived homosexual stigma and internalized homosexual stigma on sexual risk behaviors through depression and drug and alcohol use. Our study provides valuable information to our understanding of homosexual stigma in Vietnam, highlighting the need for provision of coping skills against stigma to the gay community and addressing drinking and drug use among MSM, to improve the current HIV prevention interventions in Vietnam.

Community-based interventions that work to reduce HIV stigma and discrimination: results of an evaluation study in Thailand

Introduction

HIV stigma and discrimination are major issues affecting people living with HIV in their everyday lives. In Thailand, a project was implemented to address HIV stigma and discrimination within communities with four activities: (1) monthly banking days; (2) HIV campaigns; (3) information, education and communication (IEC) materials and (4) “Funfairs.” This study evaluates the effect of project interventions on reducing community-level HIV stigma.

Methods

A repeated cross-sectional design was developed to measure changes in HIV knowledge and HIV-related stigma domains among community members exposed to the project. Two cross-sectional surveys were implemented at baseline (respondent n=560) and endline (respondent n=560). T-tests were employed to assess changes on three stigma domains: fear of HIV infection through daily activity, shame associated with having HIV and blame towards people with HIV. Baseline scales were confirmed at endline, and each scale was regressed on demographic characteristics, HIV knowledge and exposure to intervention activities.

Results

No differences were observed in respondent characteristics at baseline and endline. Significant changes were observed in HIV transmission knowledge, fear of HIV infection and shame associated with having HIV from baseline to endline. Respondents exposed to three specific activities (monthly campaign, Funfair and IEC materials) were less likely to exhibit stigma along the dimensions of fear (3.8 points lower on average compared to respondents exposed to none or only one intervention; 95% CI: −7.3 to −0.3) and shame (4.1 points lower; 95% CI: −7.7 to −0.6), net of demographic controls and baseline levels of stigma. Personally knowing someone with HIV was associated with low fear and shame, and females were less likely to possess attitudes of shame compared to males.

Conclusions

The multivariate linear models suggest that a combination of three interventions was critical in shifting community-level stigma – monthly campaign, Funfair and IEC materials. This is especially important given Thailand's new national AIDS strategy to reduce HIV-related stigma and discrimination by half by 2016. Knowing which interventions to invest in for HIV stigma reduction is crucial for country-wide expansion and scale-up of intervention activities.

The paradox of family support: concerns of tuberculosis-infected HIV patients about involving family and friends in their treatment

Despite the widely documented evidence that family support improves adherence to HIV treatment, some studies have reported no benefit or even a negative association between family support and adherence. This study reexamined the role of family support in treatment adherence to find out the circumstances under which family support for HIV and tuberculosis coinfected patients promotes or hinders treatment adherence in Cross River State, Nigeria. We conducted eight focus group discussions (FGDs) and four case histories with coinfected patients. In addition, 21 in-depth interviews (IDIs) were conducted with: 8 family members, 6 friends, and 7 care providers. Data were analyzed in a thematic format with the aid of NVIVO software. Overall, family support promotes adherence in coinfected patients. Family support may, however, have a negative effect on adherence when the recipient perceives that the support is given with ulterior motives (e.g., gossiping about them and becoming indebted to the support givers) and when the recipient is the primary breadwinner and feels that this role is being undermined. Family support is useful as a tool for scaling up adherence but the usefulness is context-specific and mediated by the patient's subjective interpretation of the support givers' motives.

How ‘alternative’ is CAM? Rethinking conventional dichotomies between biomedicine and complementary/alternative medicine

The aim of this article is to interrogate the pervasive dichotomization of ‘conventional’ and ‘alternative’ therapies in popular, academic and medical literature. Specifically, I rethink the concepts such as holism, vitalism, spirituality, natural healing and individual responsibility for health care as taken-for-granted alternative ideologies. I explore how these ideologies are not necessarily ‘alternative’, but integral to the practice of clinical medicine as well as socially and culturally dominant values, norms and practices related to health and health care in Canada and elsewhere. These reflections address both theoretical and applied concerns central to the study of integration of different medical practices in western industrialized nations such as Canada. Overall, in examining homologies present in both biomedicine and complementary/alternative medicine (CAM), this article rethinks major social practices against binary oppositions by illustrating through literature review that the biomedical and CAM models may be homologous in their original inceptions and in recent cross-fertilizations towards a rigorous approach in medicine. By highlighting biomedicine and CAM as homologous symbolic systems, this article also sheds light on the potential for enhancing dialogue between diverse perspectives to facilitate an integrative health care system that meets multiple consumer needs.

Impact of stigma, culture and law on healthcare providers after occupational exposure to HIV and hepatitis C

Worldwide, approximately three million needlestick or sharps injuries occur annually during healthcare procedures, with an estimated 18-35 healthcare professionals (HCPs) acquiring HIV each year as a result. This qualitative study examined the lived experience of occupational exposure to HIV or hepatitis C reported by four HCPs working in a tertiary care hospital in United Arab Emirates (UAE). Findings were based on interviews conducted as part of a larger two-year study investigating an intervention to improve the reporting and management of blood and body fluid exposures (BBFE) in the hospital. The data showed that due to cultural differences, individuals exposed to the same disease within the same legal system could have different concerns. Five themes arose from the data: (1) experiencing the unexpected, (2) inevitability and finality, (3) impact of stigma, (4) responsibility and risk and (5) legal and financial implications. The participants' most important concerns and causes of stress arising from occupational BBFE were related to the social implications (i.e., stigma; legal and financial costs) rather than the biological consequences of the disease. Social implications like these may negatively impact on reporting of occupational BBFE in UAE, but may need to be addressed at a societal rather than organisational level.

HIV/AIDS-Related Stigma and Discrimination: A Study of Health Care Providers in Bangladesh

People living with HIV/AIDS (PLWHA) are stigmatized and looked at negatively by people at large. Stigma, discrimination, and prejudice extend its reach to people associated with HIV-positive people such as health providers, hospital staff, as well as family member and friends. Studies demonstrate that, in low-income countries, especially in South Asia and sub-Saharan Africa, health providers' views toward the HIV-positive individuals is not very much different from the general population. The study has been qualitative in nature and conducted among health providers such as physicians and nurses attached to different hospitals. The study was conducted from March 2005 to May 2007. The study shows that 80% of the nurses and 90% of the physicians' behavior with the HIV-positive individuals were discriminatory. They talk to their patients standing far from them. The interview revealed that the spouses of the physicians and nurses in charge of the HIV-positive individuals put pressure to stop serving the patient or even quit the job. The notion that HIV is only transmitted through sexual activities is prevalent among them. Interestingly, although the physicians know well about the routes of transmission, they do not believe it by heart. Therefore, their fear of being infected makes them discriminate against the HIV-positive individuals. HIV-related stigma remains a barrier to effectively fighting this pandemic. Fear of discrimination often prevents people from seeking treatment publicly. There are evidences that they were evicted from home by their families and rejected by their friends and colleagues. The stigma attached to HIV/AIDS can extend into the next generation, placing an emotional burden on them.

The experiences of people living with HIV/AIDS and of their direct informal caregivers in a resource-poor setting

Background

HIV/AIDS is a critical concern in South Africa, where extreme poverty and gender issues are major determinants of health. A comprehensive home-based care programme is needed to lessen the burden placed on the caregivers of those suffering from HIV/AIDS. The purpose of this study was to explore and describe the challenges faced by people who are living with HIV/AIDS and by their caregivers in resource-poor, remote South African villages.

Methods

In-depth interviews were conducted with nine persons living with HIV/AIDS and their nine direct informal caregivers. Interviews explored the themes of physical, emotional and social wellbeing. Two focus groups, one involving community leaders and one with local health care providers, were conducted to build on themes emerging from the in-depth interviews. A thematic analysis of the transcripts was performed.

Results

This study sheds light on the needs of persons living with HIV/AIDS and the needs of their direct informal caregivers in a rural area of the Eastern Cape province of South Africa. These needs include: physical/medical, social, material, financial, physiological/emotional, gender issues, and instrumental.

Conclusions

In developing home-based care programmes, it is vital to consider the perceived needs of persons living with HIV/AIDS and their direct informal caregivers. The results from this study serve as a basis for the development of a home-based care programme in one resource-poor setting of South Africa and could provide a model for such programmes in similar areas.

HIV stigma, disclosure and psychosocial distress among Thai youth living with HIV

The objective of the present paper is to assess stigma and to create an abbreviated 12-item Stigma Scale based on the 40-item Berger's Stigma Scale for Thai youth living with HIV (TYLH). TYLH aged 16-25 years answered the 40-item Stigma Scale and the questionnaires on mental health, social support, quality of life and alcohol/substance use. Sixty-two (88.6%) of 70 TYLH reported at least one person knowing their serostatus. Men having sex with men were more likely to disclose the diagnosis to friends (43.9% versus 6.1%, P < 0.01) and less likely to disclose to families (47.6% versus 91.8%, P < 0.01). Women were more likely to disclose to families (90.2% versus 62.1%, P < 0.01) and less likely to disclose to friends (7.3% versus 31%, P < 0.05). The 12-item Stigma Scale was reliable (Cronbach's alpha, 0.75) and highly correlated with the 40-item scale (r = 0.846, P < 0.01). Half of TYLH had mental health problems. The 12-item Stigma Scale score was significantly associated with mental health problems (beta = 0.21, P < 0.05). Public attitudes towards HIV were associated with poorer quality of life (beta = -1.41, P < 0.01) and mental health problems (beta = 1.18, P < 0.01). In conclusion, the12-item Stigma Scale was reliable for TYLH. Increasing public understanding and education could reduce stigma and improve mental health and quality of life in TYLH.

AIDS and the stigma of sexual promiscuity: Thai nurses' risk perceptions of occupational exposure to HIV

This paper examines the culturally shaped meanings of AIDS and perceptions of accidental occupational exposure to HIV among a group of twenty nurses in Bangkok, Thailand. The findings are based on data collected as a part of a larger mixed-methods study that examined how perceptions of risk behaviours (including sexual promiscuity) shape health workers' perceptions of patients living with HIV/AIDS. Nurses' narratives revealed that despite acknowledgement of the low probability of occupational exposure to HIV, the fear of HIV infection remained and was largely driven by the enormity of the anticipated social (rather than the health) consequences of being HIV-positive. The perceived certainty of social ostracism was reinforced by participants' observations of the social rejection experienced by people living with HIV/AIDS both within and outside clinical settings. For female nurses, the dominant social perception that women living with HIV/AIDS were violators of gender norms, and thus 'guilty' victims, was an issue central to their self-identities. Ways of improving care for people living with HIV in the light of the nurses' concerns and future research are discussed.

Persons' experience of HIV/AIDS in Japan: application of Margaret Newman's theory

PURPOSE

To describe human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) persons' experience in Japan applying Margaret Newman's theory of health as expanding consciousness.

METHOD

Five men who had sex with other men and who were afflicted with HIV/AIDS were interviewed to describe their experience.

FINDINGS

Their narratives revealed an evolving pattern of the whole of five stages; self-conscious of own sexual orientation, chaos, stagnation, turning point and regaining a new identity. After viewing their pattern, their expanding consciousness was evident from their becoming compassionate for those who were underserved and underprivileged, and having deeper levels of connectedness with their family and friends. The a priori nature of theory in this praxis research was evident when the researcher embodied the theory of expanding consciousness.

RECOMMENDATIONS

The findings of the study demonstrated the relevance and importance of understanding how the condition intersects with race, gender and ethnicity in constructing the unique experience of living with HIV/AIDS. Community health workers, community mental health nurses in particular, should be cognizant of the illness trajectory of those who are afflicted with the condition. Programmes such as outreach should be carried out on an ongoing basis in order to identify and render support to those who might need help from various stages of illness. Community health workers should identify clients' specific needs to refer to appropriate services because there are physical, mental and socio-economic implications throughout illness trajectory in HIV/AIDS.

Measuring stigma associated with tuberculosis and HIV/AIDS in southern Thailand: exploratory and confirmatory factor analyses of two new scales

OBJECTIVE

To develop scales to measure tuberculosis and HIV/AIDS stigma in a developing world context.

METHODS

Cross-sectional study of tuberculosis patients in southern Thailand, who were asked to rate their agreement with items measuring TB and HIV/AIDS stigma. Developing the scales involved exploratory and confirmatory factor analyses, internal consistency, construct validity, test-retest reliability and standardized summary scores.

RESULTS

Factor analyses identified two sub-scales associated with both tuberculosis and HIV/AIDS stigma: community and patient perspectives. Goodness-of-fit was good (TLI = 94, LFI = 0.88 and RMSEA = 0.11), internal consistency was excellent (Cronbach's alphas 0.82-0.91), test-retest reliability was moderate, and construct validity showed an inverse correlation with social support.

CONCLUSION

Our scales have good psychometric properties that measure stigma associated with tuberculosis and HIV/AIDS and allow assessment of stigma from community and patient perspectives. Their use will help document the burden of stigma, guide the development of interventions and evaluate stigma reduction programmes in areas with a high HIV/AIDS and tuberculosis burden.

Stigmatization of AIDS patients: disentangling Thai nursing students' attitudes towards HIV/AIDS, drug use, and commercial sex

This paper analyzes the interrelationships between the stigma of HIV/AIDS stigma and the co-stigmas of commercial sex (CS) and injecting drug use (IDU). Students of a Bangkok nursing college (N=144) were presented with vignettes describing a person varying in the disease diagnoses (AIDS, leukemia, no disease) and co-characteristics (IDU, CS, blood transfusion, no co-characteristic). For each vignette, participants completed a social distance measure assessing their attitudes towards the hypothetical person portrayed. Multivariate analyses showed strong interactions between the stigmas of AIDS and IDU but not between AIDS and CS. Although AIDS was shown to be stigmatizing in and of itself, it was significantly less stigmatizing than IDU. The findings highlight the need to consider the non-disease-related stigmas associated with HIV as well as the actual stigma of HIV/AIDS in treatment and care settings. Methodological strengths and limitations were evaluated and implications for future research discussed.

An Asia Pacific six-country study on HIV-related discrimination: Introduction

This paper outlines a six-country study of institutionalised forms of HIV/AIDS-related discrimination in the Asia-Pacific region. Although recognised as a barrier to disease prevention and treatment, very limited data are available on the effects of institutionalised HIV-related stigma and discrimination. Understanding the forms of discrimination within the institutions where they occur is the first step to identifying effective ways of promoting compassionate, non-discriminatory treatment of PLWHA. Thus, the goal of this research project was to document institutional discrimination against PLWHA, as guided by the UNAIDS Protocol for the Identification of Discrimination Against People Living with HIV (2000), in six Asian countries: India, Thailand, Philippines, China, Vietnam and Indonesia. As a precursor to the six individual studies, this paper provides a brief overview of the literature on HIV discrimination, and then describes the UNAIDS Protocol and the shared methodological considerations relevant to all of the study sites. Commonalities in sampling, procedures and analysis are also discussed.

A situational analysis of HIV/AIDS-related discrimination in Bangkok, Thailand

Unlike its other Asian counterparts, the national prioritizing of HIV/AIDS in Thailand, through the development of a number of preventive initiatives, has resulted in a declining rate of incidence. While there are no laws overtly protecting the rights of people living with HIV/AIDS (PLWHA), substantial written policy has been enacted. Yet in spite of this highly protective legislative and policy environment, discrimination against PLWHA continues to occur in practice. Focusing on the healthcare sector, through the framework set out in the UNAIDS 'Protocol for the Identification of Discrimination against People Living with HIV' (the Protocol) this study found that discriminatory attitudes and practices arose primarily due to a lack of appropriate monitoring of levels of compliance by health care providers. The disparity between written policy and practice can be explained by the underlying personal and cultural factors and the authors strongly contend that for written policies to effectively work, further research needs to be conducted into the individual and cultural values of Thai health personnel.

Managing shame and stigma: case studies of female carers of people with AIDS in southern Thailand

The authors of this article discuss the effects of shame and stigma on female caregivers of people living with AIDS in southern Thailand. They conducted a longitudinal ethnographic case study over 8 months and collected data using interviews, observations, field notes, and journaling. The authors performed qualitative content analysis and narrative analysis. Public judgment was created in a moral climate, framed by Buddhist precepts of correct and honorable behavior, with different levels of tolerance and stigmatization between men and women. Women caregivers engaged in concealing practices, deception, and withdrawal from social relationships to manage the effects of shame and stigma.

Understanding family support for people living with HIV/AIDS in Yunnan, China

This study examines how family support affects people living with HIV/AIDS (PLHA) in China. In-depth, semi-structured interviews (n=30) were conducted with people living with HIV/AIDS who were infected through different routes (e.g., intravenous drug use, sex) and of different age groups. Findings showed that all of the participants were in great need of help and the primary source of support came from their families. Family support included financial assistance, support in the disclosure process, daily routine activities, medical assistance, or psychological support. This study illustrates that the support provided by family makes multiple levels of positive impact on people living with HIV/AIDS, suggesting the importance of including families in HIV/AIDS interventions.

Community reaction to persons with HIV/AIDS and their parents: an analysis of recent evidence from Thailand

We systematically examine community reaction to persons living with HIV/AIDS (PHAs) and their older parents in Thailand. We focus on parents as well as PHAs because parents are major providers of care for their ill adult children. Our analyses are based on several sources of recently collected survey and qualitative data from a wide range of perspectives. We find important variations in community reaction to PHAs and their families, but overall these reactions are much more positive than is widely assumed. We conclude that much existing research on community reaction to AIDS neglects both a rich body of social theory on stigma and a strong tradition of population-based empirical research in sociology. Much existing research also fails to adequately distinguish between key aspects of the social settings where most AIDS cases occur and the social settings where most of the stereotypes surrounding AIDS-related stigma have originated. A closer marriage between empirical and theoretical approaches to social stigma is required to advance our understanding of this critically important dimension of the AIDS epidemic.

AIDS-related discrimination in Asia

The Asia Pacific Network of People Living with HIV/AIDS (APN+) conducted the first regional documentation of AIDS-related discrimination in Asia. This project was an action-based, peer-implemented study that aimed to develop an understanding of the nature, pattern and extent of AIDS-related discrimination in several Asian countries. Trained HIV-positive people interviewed 764 positive people in four countries (India 302; Indonesia 42; Thailand 338; the Philippines 82) using a structured questionnaire. Findings indicate that the major area of discrimination in each country is within the health sector, where over half of those surveyed experienced some form of discrimination. In all countries, the majority of people did not receive pre-test counselling before being tested for HIV. People who reported coerced testing were significantly more likely than other respondents to face subsequent AIDS-related discrimination. A considerable number of respondents were refused treatment after being diagnosed with HIV and many experienced delayed provision of treatment or health services. Breaches of confidentiality by health workers were common. Within the family and the community, women were significantly more likely to experience discrimination than men, including ridicule and harassment, physical assault and being forced to change their place of residence because of their HIV status. These findings have serious implications, particularly in light of the increasing trend in many countries to test all pregnant women in order to prevent transmission of HIV to their unborn children.

Multiple dimensions of HIV stigma and psychological distress among Asians and Pacific Islanders living with HIV illness

Asians and Pacific Islanders (APIs) living with HIV/AIDS in the US are particularly vulnerable to HIV-related stigma largely due to ingrained socio-cultural norms that strongly associate HIV transmission with activities perceived to be immoral. This cross-sectional study examined the relationship between five HIV-stigma factors and psychological distress among 54 HIV-seropositive APIs. Social Rejection, Negative Self-Worth, Perceived Interpersonal Insecurity, and Financial Security were all significantly associated with psychological distress. Results from hierarchical multiple regression analyses indicated that Social Rejection, Negative Self-Worth, and Perceived Interpersonal Insecurity significantly predicted psychological distress after control for physical symptoms and country of birth. Undocumented Asians endorsed higher levels of Social Rejection, Negative Self-Worth and Perceived Interpersonal Insecurity than documented APIs. Future studies examining mechanisms of psychological distress among HIV-seropositive APIs are needed.

Self-evaluations of tuberculosis patients about their illnesses at Ankara Atatürk Sanatorium Training and Research Hospital, Turkey

Tuberculosis (TB) is one of the leading causes of morbidity and mortality and almost one-third of the world is infected with this disease. In Turkey, it remains an important public health concern. In many of the studies, social aspects of TB are underestimated. In this study, self-evaluations of TB inpatients between the ages of 18 and 65 were assessed between July 29 and August 01, 2002 at Ankara Atatürk Sanatorium Training and Research Hospital, which is one of the major reference hospitals for TB in Turkey. This was a cross-sectional epidemiological study in which the participation rate was 88.2%. Mean age of the total 97 participants was 41.3 (SD = 13.6) and 80.4% of patients were male. Patients expressed "unhappiness and stress (23.7%)" to be the major cause of their illness. From the patients' point of view, the three major difficulties incorporated in their lives due to TB were "financial problems (27.9%)", "loneliness (9.3%)", and "hospitalization (9.3%)". Relationships between the patients and their social environments were also assessed in five categories: "closest friend at work, closest friend in life, parents, children, and spouse".