AIDS and the urban family: its impact in Kampala, Uganda

Consequences of a Diagnostic Label: A Systematic Scoping Review and Thematic Framework

Objectives: To develop a thematic framework for the range of consequences arising from a diagnostic label from an individual, family/caregiver, healthcare professional, and community perspective.

Design: Systematic scoping review of qualitative studies.

Search Strategy: We searched PubMed, Embase, PsycINFO, Cochrane, and CINAHL for primary studies and syntheses of primary studies that explore the consequences of labelling non-cancer diagnoses. Reference lists of included studies were screened, and forward citation searches undertaken.

Study Selection: We included peer reviewed publications describing the perceived consequences for individuals labelled with a non-cancer diagnostic label from four perspectives: that of the individual, their family/caregiver, healthcare professional and/or community members. We excluded studies using hypothetical scenarios.

Data Extraction and Synthesis: Data extraction used a three-staged process: one third was used to develop a preliminary framework, the next third for framework validation, and the final third coded if thematic saturation was not achieved. Author themes and supporting quotes were extracted, and analysed from the perspective of individual, family/caregiver, healthcare professional, or community member.

Results: After deduplication, searches identified 7,379 unique articles. Following screening, 146 articles, consisting of 128 primary studies and 18 reviews, were included. The developed framework consisted of five overarching themes relevant to the four perspectives: psychosocial impact (e.g., positive/negative psychological impact, social- and self-identity, stigma), support (e.g., increased, decreased, relationship changes, professional interactions), future planning (e.g., action and uncertainty), behaviour (e.g., beneficial or detrimental modifications), and treatment expectations (e.g., positive/negative experiences). Perspectives of individuals were most frequently reported.

Conclusions: This review developed and validated a framework of five domains of consequences following diagnostic labelling. Further research is required to test the external validity and acceptability of the framework for individuals and their family/caregiver, healthcare professionals, and community.

The Initial Economic Burden of Femur Fractures on Informal Caregivers in Dar es Salaam, Tanzania

Background

Femur fracture patients require significant in-hospital care. The burden incurred by caregivers of such patients amplifies the direct costs of these injuries and remains unquantified.

Aim

Here we aim to establish the in-hospital economic burden faced by informal caregivers of femur fracture patients.

Methods

70 unique caregivers for 46 femoral shaft fracture patients were interviewed. Incurred economic burden was determined by the Human Capital Approach, using standardized income data to quantify productivity loss (in $USD). Linear regression assessed the relationship between caregiver burden and patient time-in-hospital.

Results

The average economic burden incurred was $149, 9% of a caregiver's annual income and positively correlated with patient time in hospital (p<0.01).

Conclusion

Caregivers of patients treated operatively for femur fractures lost a large portion of their annual income, and this loss increased with patient time in hospital. These indirect costs of femur fracture treatment constitute an important component of the total injury burden.

Cultural and religious determinants of HIV transmission: A qualitative study with people living with HIV in Belu and Yogyakarta, Indonesia

As a part of a larger qualitative study to understand HIV-risk factors and impacts on people living with HIV (PLHIV) (52 women and 40 men) in Belu and Yogyakarta, Indonesia, this paper reports the influences of cultural practices and religious beliefs on sexual relationships and behaviours of participants as contributors for HIV transmission. This study was conducted from June to December 2020. Data collection was conducted using one-one-one in-depth interviews. Participants were recruited using the snowball sampling technique. Data analysis was guided by a qualitative data analysis framework. The findings showed that cultural practices in Belu related to the use of bride wealth, managing spousal disputes, marriage, and condom use, influenced spousal relationships and sexual behaviours or practices which contributed to HIV transmission. Javanese cultural practices and expectation of an ‘ideal wife’, Islamic religious beliefs about expected husband-wife relationships, forbidden premarital sex, and the participants’ individual interpretation of their religious beliefs about condom use spousal sexual relations, also influenced spousal sexual relations and behaviours, which supported HIV transmission among the participants. The findings indicate the need for HIV education programs that address cultural practices and religious beliefs for community members and population groups to enhance their understanding about HIV, condom use, and how cultural practices and religious beliefs play a role in HIV transmission. The findings also indicate the need for involvement of religious leaders in HIV education programs to bring insights to people and help them interpret their religious beliefs in health promoting ways. Future studies that explore different aspects of culture and religion which may contribute to HIV transmission are recommended.

The experiences of caregivers of children living with HIV and AIDS in Uganda: a qualitative study

Background

Home-based care for HIV patients is popular in contexts severely affected by the epidemic and exacts a heavy toll on caregivers. This study aimed at understanding the experiences of caregivers and their survival strategies.

Methods

A total of 18 caregivers (3 males and 15 females) were interviewed using a semi-structured interview guide, and thematic analysis was used to analyse the data.

Results

Analysis suggests that the caregivers are burdened with insecure provisions for food and difficulties in accessing health care. They however survived these strains through managing their relationships, sharing burden with care-recipients, social networks and instrumental spirituality. These findings are discussed under two major themes: 1). Labour of caregiving and 2). Survivalism.

Conclusions

Home-based care presents huge opportunities for community response to the HIV/AIDS epidemic in African settings. It is however burdensome and thus should not be left for families alone to shoulder. There is therefore an urgent need for protecting home-based care for HIV children in Uganda. Implications for improving and strengthening social interventions in home-based care of HIV/AIDS in the Ugandan context are addressed.

A livelihood intervention to improve economic and psychosocial well-being in rural Uganda: Longitudinal pilot study

HIV and poverty are inextricably intertwined in sub-Saharan Africa. Economic and livelihood intervention strategies have been suggested to help mitigate the adverse economic effects of HIV, but few intervention studies have focused specifically on HIV-positive persons. We conducted three pilot studies to assess a livelihood intervention consisting of an initial orientation and loan package of chickens and associated implements to create poultry microenterprises. We enrolled 15 HIV-positive and 22 HIV-negative participants and followed them for up to 18 months. Over the course of follow-up, participants achieved high chicken survival and loan repayment rates. Median monthly income increased, and severe food insecurity declined, although these changes were not statistically significant (P-values ranged from 0.11 to 0.68). In-depth interviews with a purposive sample of three HIV-positive participants identified a constellation of economic and psychosocial benefits, including improved social integration and reduced stigma.

Stigma Associated With Ghanaian Caregivers of AIDS Patients

This study explores the experiences of informal caregivers of AIDS patients in Accra, the capital city of Ghana. Fifteen interviews were completed in 2002 with 11 informal caregivers, including wives, mothers, boyfriends, daughters, sons and brothers of AIDS patients. Three major themes emerge in the analysis of the interviews with caregivers: stigma, caregiver burden, and caregiver commitment. In this article, the authors focus on the theme of stigma by documenting its presence and highlighting its impact on caregiving activities. Caregivers go to great effort to not only “hide” their patients but also their care giving activities, resulting in the social isolation of both patients and their caregivers. Many caregivers live in secrecy, not sharing their family member’s diagnosis with extended family members. As a result, they receive limited support from the extended family. Stigma results in negative attitudes of neighbors, relatives, and health care workers toward caregivers and their patients.

Structuration Theory: A Conceptual Framework for HIV/AIDS Stigma

The continuing paucity of effective interventions to reduce HIV/AIDS stigma is troubling, given that stigma has long been recognized as a significant barrier to HIV prevention, treatment, care, and support. Ineffectual HIV/AIDS stigma-reduction interventions are the product of inadequate conceptual frameworks and methodological tools. And while there is a paucity of effective interventions to reduce stigma, there is no shortage of conceptual frameworks intending to offer a comprehensive understanding of stigma, ranging from sociocognitive models at the individual level to structural models at the macrolevel. Observations highlighting inadequacies in the individualistic and structural models are offered, followed by the theory of structuration as a possible complementary conceptual base for designing HIV/AIDS stigma-reduction interventions.

Knowledge and Attitude about HIV/AIDS among HIV-Positive Individuals in Davangere

A cross-sectional study was carried out on 100 HIV patients (55 male and 45 female) age 21 years and older registered at the Antiretroviral Therapy Centre of Chigateri General Hospital, Davangere, Karnataka, India, to evaluate their knowledge and attitude toward HIV. Overall, the source of knowledge about AIDS was through newspaper or television, 38% were aware of their AIDS status, 61% disclosed their status to family, 86% had incorrect knowledge about transmission, 57% experienced no moral support, 62% felt stigmatized, 52% discriminated against, 44% were denied treatment, 57% felt isolated, 54% experienced difficulty in carrying out daily activity, 52% of patients' social and personal life was affected, and 41% felt shy when disclosing their disease. This data reveals the need to consider the basic knowledge of the HIV patients about HIV/AIDS.

Challenging power and meaning: outlining the popular epidemiology of HIV and AIDS in Rakai, Uganda, c. 1975-1990

This article traces the historical evolution of conditions that favoured the spread of HIV in Rakai district, Uganda, and the process of evolution of the local, popular epidemiology of HIV and AIDS. It argues that the HIV epidemic was made possible by economic and social disparities, which grew more pronounced since the mid-1970s as a result of economic decline, physical insecurity, and the disbanding of public services. The local constructions of AIDS in Rakai have changed and shifted according to the progress of the epidemic, eventually challenging the initial cultural construction of the disease, based on local notions about causality between disease and morality. The progress of the epidemic undermined the local intellectual authority (e.g. traditional healers, health workers, and religious leaders), creating a need to produce additional explanations of the disease. The concept of 'Slim' in Rakai emerged as a popular construct to denote the physical, psychological and social consequences of HIV disease. The concept reflects popular concerns over the outcomes of the epidemic rather than its cause, being more concerned about the fate of individuals and communities than about issues of morality. Later, the moral construction of 'Slim' that accompanied the biomedical categorisation of AIDS as a sexually transmitted disease made it appear as a disease of sexual indulgence and promiscuity. The bio-moral construction of 'Slim' was also challenged by local evangelical claims about the power of faith and morality to regenerate its 'victims,' something that biomedicine had not been able to provide. As the disease has become part of the social ecology of Rakai and the rest of Uganda, interpretations of it will continue to be challenged and reconstructed.

On the road to HIV/AIDS competence in the household: building a health-enabling environment for people living with HIV/AIDS

When aiming to provide chronic disease care within the context of human resource shortages, we should not only consider the responsibility of the individual person living with HIV/AIDS (PLWHA) but also the capacity of the social environment to actively encourage a lifestyle that fosters health. In this social environment, extensive efforts are thus required to increase HIV/AIDS knowledge, reduce stigma, stimulate HIV testing, improve health care-seeking behavior, and encourage safe sexual practices—described in the literature as the need for AIDS competence. In accordance with socio-ecological theory, one cannot restrict the research focus to communities, as AIDS competence studies should also incorporate the intermediate household level. In responding to this research need, the aim of this article is to conceptualize an “HIV/AIDS competent household” based on qualitative interviews and focus group discussions conducted in a township on the outskirts of Cape Town, South Africa. Our results show that a household’s supportive response to disclosure allows a patient to live openly as HIV positive in the household concerned. This may mark the start of the road to HIV/AIDS competence in the household, meaning the PLWHA receives sustainable support throughout the care continuum and positive living becomes the norm for the PLWHA and his or her household. A feedback loop might also be created in which other household members are encouraged to be tested and to disclose their status, which is an important step towards a sustainable response to HIV/AIDS-related challenges. Despite the fact that this road to HIV/AIDS competence at the household level is fragile and prone to various barriers, this article shows that the household has the potential to be a health-enabling environment for PLWHA.

Internalized stigma, social distance, and disclosure of HIV seropositivity in rural Uganda

BACKGROUND

HIV is highly stigmatized, compromising both treatment and prevention in resource-limited settings.

PURPOSE

We sought to study the relationship between internalized HIV-related stigma and serostatus disclosure and to determine the extent to which this association varies with the degree of social distance.

METHODS

We fit multivariable Poisson regression models, with cluster-correlated robust estimates of variance, to data from 259 persons with HIV enrolled in an ongoing cohort study in rural Uganda.

RESULTS

Persons with more internalized stigma were less likely to disclose their seropositivity. The magnitude of association increased with social distance such that the largest association was observed for public disclosures and the smallest association was observed for disclosures to sexual partners.

CONCLUSIONS

Among persons with HIV in rural Uganda, internalized stigma was negatively associated with serostatus disclosure. The inhibiting effect of stigma was greatest for the most socially distant ties.

HIV/AIDS stigma and utilization of voluntary counselling and testing in Nigeria

BACKGROUND

Despite the recognition of stigma as a hindrance to public health treatment and prevention there are gaps in evidence on the relationship between HIV stigma and VCT services utilization in Nigeria. The purpose of this study was to examine a community's perceptions, feelings and attitudes towards people living with HIV/AIDS and how this is associated with access to utilization of voluntary counselling and treatment in Nigeria.

METHODS

A cross-sectional random study of Nigerians, using a mixed-method approach was carried out in two distinct ethnic areas of the country. Both quantitative and qualitative methods (mixed-methods) were used to collect data in Osun State (Yoruba ethnic group) in the South-West and Imo State (Igbo ethnic group) in the South East. Multivariate logistic regression was the model used to examine the association of interest.

RESULTS

It is shown that Nigerian public attitudes to HIV/AIDS and those infected with the disease are negative. The markers for stigma on the overall stigma index are significant predictors of utilization of voluntary counselling and testing. As the sum of negative feelings increases, there is less likelihood to using voluntary counselling and testing (VCT) and vice versa.

CONCLUSIONS

Current national efforts at addressing the AIDS pandemic can only be successful when the issue of AIDS is de-stigmatized and is made a critical part of those efforts. One way to do this is through well-designed messages that should be posted in the media, community halls, health centers and other public places aimed at humanizing the disease and those affected and infected by it.

Structuration Theory: A Conceptual Framework for HIV/AIDS Stigma

The continuing paucity of effective interventions to reduce HIV/AIDS stigma is troubling, given that stigma has long been recognized as a significant barrier to HIV prevention, treatment, care, and support. Ineffectual HIV/AIDS stigma-reduction interventions are the product of inadequate conceptual frameworks and methodological tools. And while there is a paucity of effective interventions to reduce stigma, there is no shortage of conceptual frameworks intending to offer a comprehensive understanding of stigma, ranging from sociocognitive models at the individual level to structural models at the macrolevel. Observations highlighting inadequacies in the individualistic and structural models are offered, followed by the theory of structuration as a possible complementary conceptual base for designing HIV/AIDS stigma-reduction interventions.

Global health justice and governance

While there is a growing body of work on moral issues and global governance in the fields of global justice and international relations, little work has connected principles of global health justice with those of global health governance for a theory of global health. Such a theory would enable analysis and evaluation of the current global health system and would ethically and empirically ground proposals for reforming it to more closely align with moral values. Global health governance has been framed as an issue of national security, human security, human rights, and global public goods. The global health governance literature is essentially untethered to a theorized framework to illuminate or evaluate governance. This article ties global health justice and ethics to principles for governing the global health realm, developing a theoretical framework for global and domestic institutions and actors.

The social context of food insecurity among persons living with HIV/AIDS in rural Uganda

HIV/AIDS and food insecurity are two of the leading causes of morbidity and mortality in sub-Saharan Africa, with each heightening the vulnerability to, and worsening the severity of, the other. Less research has focused on the social determinants of food insecurity in resource-limited settings, including social support and HIV-related stigma. In this study, we analyzed data from a cohort of 456 persons from the Uganda AIDS Rural Treatment Outcomes study, an ongoing prospective cohort of persons living with HIV/AIDS (PLWHA) initiating HIV antiretroviral therapy in Mbarara, Uganda. Quarterly data were collected by structured interviews. The primary outcome, food insecurity, was measured with the Household Food Insecurity Access Scale. Key covariates of interest included social support, internalized HIV-related stigma, HIV-related enacted stigma, and disclosure of HIV serostatus. Severe food insecurity was highly prevalent overall (38%) and more prevalent among women than among men. Social support, HIV disclosure, and internalized HIV-related stigma were associated with food insecurity; these associations persisted after adjusting for household wealth, employment status, and other previously identified correlates of food insecurity. The adverse effects of internalized stigma persisted in a lagged specification, and the beneficial effect of social support further persisted after the inclusion of fixed effects. International organizations have increasingly advocated for addressing food insecurity as part of HIV/AIDS programming to improve morbidity and mortality. This study provides quantitative evidence on social determinants of food insecurity among PLWHA in resource-limited settings and suggests points of intervention. These findings also indicate that structural interventions to improve social support and/or decrease HIV-related stigma may also improve the food security of PLWHA.

Psychosocial profile of people with AIDS and their caregivers in Egypt

Caring for individuals with AIDS in developing countries represents a major crisis to families and natural caregivers. This study presents the psychosocial profiles of people with AIDS and their caregivers in Egypt to assess the effects of HIV/AIDS on patients, their caregivers, and the factors that influence caregiving and support. Various stressors and challenges for patients as well as hardships the caregiver faces were explored. The literature documents difficulties such as inadequate health care services, lack of resources, and stigma that patients experience in developing countries. Findings indicate an association between the psychosocial effects of AIDS on patients and their caregivers.

A qualitative study of the impact of HIV/AIDS on agricultural households in Southeastern Uganda

The HIV/AIDS pandemic threatens economic, social, and environmental sustainability throughout sub-Saharan Africa. This paper reports on a qualitative study exploring interrelationships between HIV/AIDS, labor availability, agricultural productivity, household resources, food consumption, and health status in rural southeastern Uganda. Respondents reported an increase in widow-and-orphan-headed households; labor shortages due to illness and caretaking; degradation of household resources from health-related expenses; loss of land tenure and assets following deaths, especially for widows and orphans; and changes in agricultural practices and productivity. Our study highlights a potential downward spiral of livelihood degradation for vulnerable households and suggests targeted interventions to improve sustainability.

Stress, needs, and quality of life of family members caring for adults living with HIV/AIDS in Taiwan

The stress, needs and quality of life (QoL) of family members of people living with HIV/AIDS (PLWHA) are critical to explore in Taiwan where home care projects are not available to help the PLWHA families. We examined the extent of stress, needs, QoL and its correlates that family caregivers of PLWHA experienced with structural questionnaires survey. A total of 50 family caregivers of PLWHA visiting a medical center in Taiwan participated in the study from October 2005 to August 2006. Family caregivers felt most stressful on disclosure and stigma issues, and most worried about patients' interpersonal relationships. The most important needs were care-related needs including knowledge of the disease progression, methods of examination and treatment, and the related side effects. The level of stress significantly positively correlated with needs, and negatively correlated with QoL. Availability of alternative manpower to care PLWHA and being PLWHA's parents were two significant factors affecting family caregivers' QoL. In conclusion, family members of PLWHA experienced high level of stress, enormous caring needs, and poor QoL. A family-centered care for PLWHA and their families in the community is crucial to improve quality of care and to prevent family's overload, particularly for families with no alternative manpower and for those being PLWHA's parents.

HIV/AIDS and the health of older people in the slums of Nairobi, Kenya: results from a cross sectional survey

BACKGROUND

The proportion of older people is increasing worldwide. Globally, it is estimated that older people (those 60 years or older) constitute more than 11% of the population. As the HIV/AIDS pandemic rages in sub-Saharan Africa (SSA), its impact on older people needs closer attention given the increased economic and social roles older people have taken on as a result of increased mortality among adults in the productive age groups. Few studies have looked at older people and their health in SSA or indeed the impact of HIV/AIDS on their health. This study aims to assess the effect of being directly or indirectly affected by HIV/AIDS on the health of older people in two Nairobi slums.

METHODS

Data were collected from residents of the Nairobi Urban Health and Demographic Surveillance area aged 50 years and above on 1st October 2006. Health status was assessed using the short SAGE (Study on Global AGEing and Adult Health) form and two outcome measures--self-rated health and a composite health score--were generated. To assess HIV/AIDS affected status, respondents were asked: Have you personally been affected by HIV/AIDS? If yes, a follow up question: "How have you been personally affected by HIV/AIDS?" was asked. Ordinallogistic regression was used in models with self-rated health and linear regression in models with the health score.

RESULTS

About 18% of respondents reported being affected by HIV/AIDS in at least one way, although less than 1% reported being infected with HIV. Nearly 60% of respondents reported being in good health, 27% in fair health and 14% in poor health. The overall mean health score was 70.6 (SD: 13.9) with females reporting worse health outcomes than males. Respondents directly or indirectly affected by HIV/AIDS reported worse health outcomes than those not affected: mean health score: 68.5 and 71.1 respectively (t = 3.21, p = 0.0007), and an adjusted odds ratio of reporting poor health of 1.42 (95%CI: 1.12-1.80).

CONCLUSION

Poor health outcomes among older people affected by HIV/AIDS highlight the need for policies that target them in the fight against HIV/AIDS if they are to play their envisaged care giving and other traditional roles.

HIV-related stigma, service utilization, and status disclosure among truck drivers crossing the Southern borders in Brazil

HIV-related stigma and discrimination (S&D) have been shown to impede prevention, care and treatment. Yet, few quantitative studies have tested the associations between stigma, service utilization and status disclosure, especially in countries with concentrated HIV epidemics. Surveys, administered to a random sample of 1,775 truck drivers crossing Southern borders in Brazil, included items on multiple conceptual domains of S&D, such as fear of casual contact and blame towards people living with HIV/AIDS. Pearson's chi-square tests and logistic regression were used to examine correlations. Less stigma (both individual items and grouped as a scale) was significantly correlated with VCT use (p<or=0.001), knowing where to get tested (p<or=0.001) and willingness to disclose HIV-positive test results (p=0.013). Findings indicate that stigma is an important barrier to HIV testing and disclosure among truck drivers in Southern Brazil. Learning more about stigma is important given the growing assertions that testing is a 'critical gateway' to HIV prevention and treatment. As access to HIV testing and treatment improves, providers increasingly need to understand and address how stigma acts as a barrier to services.

Gender roles and informal care for patients with AIDS: a qualitative study from an urban area in Tanzania

As HIV/AIDS imposes an overwhelming pressure on the capacity of an already overburdened health care system in many African countries, families have increasingly been noted to supplement hospital care services for patients with AIDS. The aim of the present study is to generate knowledge on the experiences of family caregivers to the patients with AIDS at the household level in Dar es Salaam, Tanzania. Data were collected through in-depth interviews with 20 family caregivers and were analyzed using thematic content analysis. The article provides the reader increased insight on the obligations that AIDS caregiving has imposed on women within the close kin group of the patient. The study indicates that caregiving has increased the workload and in the same vein the economic marginality of women, who themselves are increasingly widowed heads of households. The study findings demonstrate strong gendered implications for community and policy makers.

Caregivers' experiences with major depression concealed by physical illness in patients recruited from central Ugandan Primary Health Care Centers

In this article, we present caregivers' grapples with major depression seen among their physically ill patients. A thematic analysis of 29 in-depth caregiver interviews identified four themes: (a) caregivers' perceptions of depression, (b) barriers to caregivers' focus on depression, (c) resources and opportunities for managing depression, and (d) caregivers' perspectives on consequences of depression. Patients' physical illnesses concealed depressive episodes. Caregivers could not apply the label of "depression" but enumerated its indicative features. Stigmatization of depression, common with other mental illnesses and poverty, undermined caregiving. Vital caregiving resources included caregivers' willingness to meet patients' basic needs, facilitating patients' access to health care, informal counseling of patients, and ensuring patients' spiritual nourishment. Caregivers' management of depression in physically ill patients was expensive, but they coped; however, caregiving was burdensome. Ongoing support should be given not only to patients but caregivers, as well. To provide appropriate care, caregivers deserve sensitization about depression in the context of physical illness.

HIV/AIDS, income loss and economic survival in Botswana

In countries facing severe HIV/AIDS epidemics, the overwhelming majority of those who are infected and affected by HIV are already living in poverty. Further income loss can threaten the ability to meet basic needs such as food, education and access to healthcare. Due to this, understanding the impact of HIV infection and caregiving on household income is essential to improving the health and welfare of HIV-affected individuals and families. This qualitative study examines how HIV infection and HIV caregiving affect household income in a population located within Botswana, a country with high HIV prevalence. We find that extended unpaid leave from work or job loss are common consequences and are associated with failure to meet basic needs in the short and long-term. We make recommendations for policy and programme support, including workplace adaptations and public sector support for meeting health and basic needs of HIV-affected families.

Informal HIV caregiving in a vulnerable population: toward a network resource framework

For the impoverished and often stigmatized communities most affected by HIV/AIDS, needs for informal caregiving present tremendous demands on already limited resources. Traditional theoretical frameworks emphasize care needs as driving informal caregiving. The proposed theoretical framework emphasizes microsocial processes that may affect informal caregiving among economically disadvantaged populations. The study examined: (1) network structural factors (homophily) that may affect availability of ties and local sociocultural expression of ties (social roles, behavioral norms) and (2) the role of financial resources in enabling informal caregiving. Low income, African American injection drug using persons living with HIV/AIDS (PLHAs) and their primary HIV supporters were interviewed. Supporters were predominantly female (71%), consanguineal kin (59%) and partners or friends (41%). Compared to the general US population, supporters were disproportionately HIV-infected, drug using, African Americans of poor health and low socioeconomic status. Supporters who perceived their PLHA tie needed informal care, compared to those who perceived no care need, were more than twice as likely to report a history of drug use, functional limitation (IADLs), higher income, and PLHA's financial reliance. Supporters' reported care provision was associated with their financial resources, but not PLHAs' health status. PLHAs' reported care receipt was associated only with their health status.HIV supporters' reported care provision was affected by financial factors, consistent with the proposed theoretical framework, while PLHAs' perceptions of care receipt conformed to traditional "needs"-based frameworks of caregiving. Results suggest that programs are needed to bolster network financial resources of disadvantaged populations affected by HIV to promote and sustain their informal HIV caregiving. Findings may aid in the understanding of informal caregiving as a social process. Network resource-oriented research may allow for ascertainment of community caregiving capacity, and guide the development of interventions to promote HIV caregiving in disadvantaged populations.

Shrouded in secrecy: breaking the news of HIV infection to Ghanaian women

The purpose of this research was to examine the experience of HIV-positive Ghanaian women and to identify factors that influenced their vulnerability to infection. The study was carried out in Ghana from January to May 1999 using participatory action research. In-depth interviews and focus groups with 31 HIV-positive women, 5 HIV-positive men, 8 nurses, 10 professionals, and 2 traditional healers were used to collect the data. The need for secrecy in "breaking the news" emerged as an important theme. Secrecy affected the women's access to treatment and to financial and emotional support from families. The secrecy surrounding breaking the news of HIV infection is one manifestation of AIDS stigma in Ghana. Encouraging disclosure within a trusting and supportive environment may be one strategy to diffuse AIDS stigma in Ghana. Educational interventions to eliminate AIDS stigma among health care professionals, including nurses, are required in Ghana.

The relationship of maternal and child HIV infection to security of attachment among Ugandan infants

This study was designed to examine the relationship of maternal and child human immunodeficiency virus (HIV) infection to the security of attachment of Ugandan infants. The attachment patterns of two groups of Ugandan mother-infant pairs: 35 HIV-positive mothers and their infants and 25 HIV-negative mothers and their infants were compared. We tested the hypothesis that infants of HIV-positive mothers would demonstrate less secure attachment as measured by the Waters Attachment Q-set than infants of HIV-negative mothers. No differences were found in the security of attachment of infants of HIV-positive versus HIV-negative mothers. Infants of HIV-positive mothers with Acquired Immunodeficiency Syndrome (AIDS) were less securely attached than infants of mothers without AIDS. These findings underscore the relationship of infant security of attachment to maternal HIV infection in the presence of AIDS-related symptoms but not to asymptomatic maternal HIV infection.

A study of the experiences of women living with HIV/AIDS in Uganda

This small descriptive study investigated the experiences of Ugandan women living with a diagnosis of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), exploring what assisted them to cope and identifying their future concerns. A purposeful sample of seven HIV-positive women was accessed through two indigenous non-governmental organizations in Eastern Uganda. Single semi-structured interviews were conducted on location. Following analysis of the narrative data, three principal aspects of their experiences emerged: loss and adversity, constructive living, and future uncertainties. Loss and adversity encompassed bereavements, multiple psychosocial losses and physical suffering. Constructive living related to the ability to adopt positive living activities, rebuilding shattered lives, sometimes from the brink of despair. Since the participants were all mothers, future concerns focused on child care anxieties. Stress and uncertainty surrounding HIV testing of children was also evident. Despite the cultural contrast, many of the findings were remarkably similar to those documented in Western literature. The women related their experiences with an absence of self-pity or resentment. Resilience, resourcefulness and hope were typically, perhaps instinctively, demonstrated.

Factors influencing marital stability among HIV discordant couples in northern Thailand

The burden of HIV in stable relationships places emotional, economic and physical stresses on families. We compared the influence of HIV notification on marital partnerships in northern Thailand among a cohort of HIV discordant couples, and identified factors associated with marital disruption. Data were collected using in-depth interviews with both members of six separated or divorced couples and 13 couples whose relationship remained intact. Five factors influenced marital stability following HIV notification: longer duration of relationship; economic constraints, extended family members' opinions, especially parents; the existence of children from the marriage; and fear of stigmatization by community members. Social influences, both overt and perceived, are important in shaping marital behaviour and decision-making in HIV epidemic areas. HIV counselling needs to be extended beyond the individual seeking testing to include stable partners (and perhaps further, to include the extended family), although it is recognized that this is not the norm for most HIV testing centres.

A psychological epidemiology of people seeking HIV/AIDS counselling in Kenya: an approach for improving counsellor training

OBJECTIVE

This study develops a typology of psychological problems reported during HIV/AIDS counselling. This typology provides a framework for training paraprofessional counsellors (PPCs) in East Africa.

DESIGN

Study participants included 307 Kenyans tested for HIV at any of six clinics in Nairobi specialising in STDs, tuberculosis and other infectious diseases. Pre-test, post-test, and follow-up counselling was provided by 16 PPCs who are themselves HIV-positive. Data consisted of demographic, physical and psychological information reported by 168 clients who sought follow-up counselling.

METHODS

Counselling data were coded using an ipsative method; a unique code was assigned to every distinct topic. Factor analysis with a Varimax rotation reduced the original psychological variables into logical groupings. Multivariate analysis examined the relationship of factors and demographic characteristics.

RESULTS

Clients reported 1-10 physical and 1-23 psychological complaints in a single session. Sixty-five percent of female clients reported > or = eight psychological problems; 49% of males reported > or = eight psychological problems. Factor analyses allowed the 109 reported psychological events to be assigned to 15 categories of problems. Multivariate analyses explained little of the variance in the relationship between each client's demographic profile and the psychological factors.

CONCLUSIONS

Training for PPCs should be relevant to problems encountered during counselling. Results indicate that PPCs can expect clients to present one or more of the 15 factors during counselling. Demographic characteristics explained small amounts of variance in the distribution of factor scores. The 15 factors produced in this study, although descriptive and preliminary, could form the basis of a training curriculum for HIV PPCs.

Family responses to HIV/AIDS in Mexico

This paper presents findings from a qualitative study of household and community responses to HIV/AIDS in Mexico. Fieldwork took place in two contrasting settings: (a) Ciudad Netzahualcóyotl, a socially marginalized urban community and (b) the homosexual community of Mexico City, a sexually marginalized social network. 113 in-depth interviews were conducted with people with HIV/AIDS, their relatives and members of their social networks. This paper describes findings from interviews conducted with family members of persons with AIDS. Four stages of response are identified and characterized within each community: (i) life before AIDS, (ii) life during the discovery of AIDS, (iii) living with a person with AIDS and (iv) surviving those who have died from AIDS. The social marginalization of both communities is central in explaining how families respond to the disease. In Ciudad Netzahualcoyotl, social support derives from a local culture of kinship. In the gay community, on the other hand, solidarity arises out of friendship. Between social support and discrimination, many more "ambivalent" behaviours (neither fully supportive nor discriminating) are displayed by family members and friends. Fear, pre-existing family conflicts and prejudice nurture these negative responses. Family responses and the processes to which they give rise, also differ depending on whether or not a male or female household member is affected. Policy recommendations are made concerning how best to promote positive family and household responses to persons with HIV/AIDS and how to inhibit negative ones.

Impact of HIV on families of HIV-infected women who have recently given birth, Bangkok, Thailand

The objective of this study was to assess changes in the family situation of HIV-infected women who have recently given birth. As part of a prospective perinatal HIV transmission study, interviews were conducted with a subset of HIV-infected women at 18 to 24 months postpartum, and answers were compared with baseline information obtained during pregnancy. Standardized scales were used to assess levels of psychosocial functioning. A convenience sample of 129 HIV-infected women enrolled during pregnancy was interviewed at 18 to 24 months postpartum. At delivery, the women were young (median age, 22 years), primiparous (57%), and asymptomatic (93%). When baseline and follow-up data were compared, more women were living alone (1% versus 6%; p = 0.03), fewer women were living with their partners (98% versus 73%; p < 0.001), and 30% of families had reduced incomes. At follow-up, 10% of partners had died, and more partners than wives had become ill or died (21% versus 4%; p = 0.02). Most children (78%) were living with their mothers, but only 57% of the HIV-infected women were the primary caretakers. Fewer women had disclosed their HIV status to others (e.g., family, friends) than to their partners (34% versus 84%; p < 0.001), largely because of fear of disclosure. The women appeared to have high levels of depression and worry. The women's greatest worries were about their children's health and the family's future. Within 2 years after childbirth, substantial change within the families of HIV-infected women was evident. These were manifest by partner illness or death, family separation, reduced family income, shifting responsibilities for child care, and signs of depression and isolation. Providing family support is a major challenge in Thailand as the perinatal HIV epidemic progresses.

Social aspects of AIDS-related stigma in rural Uganda

In the process of collecting sexual behaviour data through in-depth interviews, 24 respondents offered information on stigma related to HIV-1 infection. Observations of social relations in public places and families of infected individuals were made. The findings suggest that although HIV/AIDS-related stigma has had adverse effects on treatment seeking behaviour of PWAs and coping mechanisms of their families, a more tolerant attitude is starting to emerge in this area. Probably, due to improvements in counselling services and home care schemes for those with AIDS. This supports the call for increased investments in counselling and community development aimed at caring for people with AIDS (PWAs).

The prevalence and aetiology of persistent diarrhoea in adults in urban Zambia

As the AIDS pandemic has spread, diarrhoea in adults has become a major burden on health care institutions in central Africa and on the families of sufferers. In order to assess the magnitude of the problem, we carried out a survey of households in a high population density township of Lusaka to determine the prevalence of persistent diarrhoea in adults. We also carried out a study of the causes of persistent diarrhoea in patients attending the University Teaching Hospital, Lusaka. The community survey assessed 460 households, representing a sample of 1440 adults. 94 adults were reported as having had diarrhoea in the 2 weeks prior to the survey, implying an attack rate of 1.74 per adult per year. Of these 94 cases, six had diarrhoea of between 2 and 4 weeks duration, and ten had diarrhoea of over 4 weeks duration. In the hospital study, 75 (97%) out of 77 patients with diarrhoea of over 1 months' duration were HIV seropositive; potentially pathogenic parasites were found in 61/75 (81%) of seropositives. This information indicates that persistent diarrhoea in adults, mostly related to HIV infection, is likely to be an important and growing reservoir of enteric pathogens and represents a significant burden on hospitals and relatives. This emerging problem in sub-Saharan Africa may foreshadow developments in other continents.

AIDS in Africans living in London

OBJECTIVES

To investigate the presentation of HIV infection and AIDS amongst Africans diagnosed with AIDS living in London.

METHODS

Identification of all AIDS cases of African origin attending four HIV specialist centres in South London--Guy's, King's, St George's and St Thomas' Hospitals--up to March 1994, by retrospective review of case notes of all HIV positive patients.

RESULTS

Of 86 patients (53 women, 33 men) studied, 59 (69%) were from Uganda. The most frequent AIDS-defining diagnoses were: Pneumocystis carinii pneumonia (PCP) 21%, tuberculosis (TB) 20% (extrapulmonary TB 14%, pulmonary TB 6%), cerebral toxoplasmosis 14%, oesophageal candida 13%, cryptococcal meningitis 11%, wasting 6%, herpes simplex infection > 1 month 5%, Kaposi's sarcoma 5%, other 6%. Cytomegalovirus retinitis was diagnosed in one case. Late presentation was common; 70% were diagnosed HIV positive when admitted to hospital. The diagnosis of AIDS was coincident with a first positive HIV test result in 61%. The mean CD4 counts at both HIV and AIDS diagnoses were similar in both men and women: 87 x 10(6)/l and 74 x 10(6)/l in men and 99 x 10(6)/l and 93 x 10(6)/l in women respectively. Overall, TB 21 (24%) (extrapulmonary TB 12, pulmonary TB 9) was either the AIDS-defining diagnosis or was detected within three months of this event. Sixty-two per cent of TB cases were diagnosed within twelve months of entry to the UK compared to 34% of all other AIDS cases. The prevalence of STD was very low; genital herpes was the commonest STD: 17% of the women, 9% men; 28% of the men and 11% of the women tested had a positive TPHA test. In cases known to be HIV-positive prior to an AIDS diagnosis, 41% took prophylaxis for PCP and 45% had taken zidovudine (ZDV). Forty two of the study participants had 89 children: 59 of these children had mothers in the study. Overall, 37 (42%) of the children had lost at least one parent at the time of data assessment.

CONCLUSIONS

PCP and TB were the most common initial AIDS-defining diagnoses. The majority of TB cases were diagnosed within 12 months of entry to the UK. An AIDS-defining diagnosis was the first manifestation of HIV-related illness in the majority of patients. Because of late presentation to medical services, access to treatments for HIV infection and prophylaxis against opportunistic infections was limited. Extending the role of clinics and staff into the community might facilitate both earlier presentation and access to services. Future provision of local services will need to be sensitive to the requirements of individuals from different cultures and backgrounds.

HIV in the accident and emergency department

This article is intended as an introduction to some of the issues which arise from the increasing incidence in the UK of human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS). It is not possible fully to address, nor offer answers to, all of these issues. HIV and AIDS present many challenges to nurses. It tests not only our skills and methods of practice, but confronts our feelings about people whose lifestyles and behaviours may be different from our own (Lert & Marne 1992; McGrath et al 1993); it has also prompted us to alter our awareness and knowledge of medical, nursing and infection control issues. Hopefully this article will serve to stimulate reflection, thought and discussion as well as generating further, more specific papers of relevance to the Accident and Emergency nurse.

Evaluation of a home-care/counselling AIDS programme in Kgatleng district, Botswana

In 1988 a programme for care and follow-up of HIV-positive persons and AIDS patients was implemented by the existing health facilities (district health team and hospital team) of Kgatleng District, Botswana. A survey study in 1991 tried to indicate the effectiveness and bottlenecks of the programme. All advisory nurses (AN) were interviewed via two questionnaires: one pertaining to case management of clients and one on their perceptions of their work. Seventy-two of 109 HIV-infected persons accepted and received counselling. Response of the 72 varied: 26 with a good, 34 with a moderate and 12 with a bad response. Prevention, contact tracing and home visiting were studied, as well as ANs' experiences and opinions of the programme. Some behavioural change by clients was indicated by the results though its extent remains questionable. Programme problems included client migration and refusal of counselling, and discontinuation of HIV-testing facilities. Once a relationship was established, confidentiality, questions and fear of stigmatization posed major problems. One-to-one support of ANs could help them cope better with these problems as well as discuss their own worries.