La vida normal: living with HIV in Santo Domingo, Dominican Republic

Trajectories of HIV management among virally suppressed and unsuppressed female sex workers in the Dominican Republic: A comparative qualitative analysis

PURPOSE

Despite suboptimal HIV outcomes among female sex workers (FSW), limited research has been conducted on factors that impact viral suppression among this population. Examining narratives of HIV management, we examined how experiences of diagnosis, treatment initiation, and ongoing care behaviours shaped viral suppression outcomes over time.

METHODS

We conducted 20 in-depth interviews with FSW in Santo Domingo, Dominican Republic. Using narrative and thematic qualitative approaches, we developed analytic summaries and matrices to compare trajectories of managing HIV between suppressed and unsuppressed participants.

RESULTS

Regardless of suppression status, participants described similar narratives of overcoming initial challenges to HIV management through personal resilience and social support. Unsuppressed participants identified more delays in initiating antiretroviral therapy and more lapses in adherence due to less active acceptance of their HIV status and more persistent experiences of economic hardship and HIV stigma.

CONCLUSIONS

We found that individual, interpersonal and structural factors, including stigma and economic precarity, differentiated trajectories towards viral suppression among FSW indicating the importance of multilevel interventions. Improved access to mental health services and social support could promote greater early acceptance of HIV status and progress towards viral suppression among FSW.

Exploring gender differences in HIV-related stigma and social support in a low-resource setting: A qualitative study in the Dominican Republic

HIV-related stigma can affect health by compromising coping and social support. Gender differences in stigma experiences and social support are underexplored, particularly in the Caribbean. We conducted semi-structured interviews (N = 32) with patients at two HIV clinics in the Dominican Republic. Transcripts were coded using qualitative content analysis (deductive and inductive approaches) to identify themes regarding stigma experiences and social support, which were then compared across men and women participants to identify gender differences. While both men and women described experienced stigma, including verbal abuse, men's experience of stigma were subtler and women described outright rejection and instances of physical violence, including intimate partner violence. Both men and women described job discrimination, but women described severe disempowerment as well as permanent loss of income and/or employment whereas men described temporary changes in employment and /or decrease in income. Men and women described modifying behavior due to anticipated stigma, but only women discussed isolating themselves and discomfort taking HIV medication in front of others. Regarding internalized stigma, both men and women described shame, guilt, and depression over their HIV status, though these experiences were more common among women. Women's experiences prevented health care seeking and included suicidality, while men sometimes blamed women for their HIV status and expressed a desire to "move on" and "look ahead." Both men and women described receiving financial support from family and friends, community support from neighbors, governmental support, and support from other people living with HIV. Women most frequently discussed receiving support from family and friends and using religiosity to cope, whereas men referenced general family support and government benefits and were less forthcoming about personal relationships and social networks, oftentimes not disclosing HIV status to others. The social context of HIV-related stigma affects women and men differently with physical and mental health impacts and may require distinct mitigation approaches.

The co-management of HIV and chronic non-communicable diseases in the Dominican Republic: A qualitative study

People living with HIV and a non-communicable disease (NCD) experience multi-level barriers when co-managing multiple conditions. We explored the factors affecting living with multiple chronic conditions in the Dominican Republic. We conducted 21 in-depth interviews from October 2019-February 2020 with Dominican adults who participated in a food security intervention and managed HIV and at least one chronic NCD. Using thematic analysis, we explored participant lived experiences co-managing multiple chronic conditions. All participants (mean age = 45.5 years) were linked to HIV care, but only three were linked to NCD-specific care. Individual-level barriers to managing NCDs included limited education and limited self-efficacy for self-management. Interpersonally, barriers included limited rapport building with an NCD-specific specialist. Structural barriers to managing NCDs were no health insurance, poor referral systems, and limited financial assistance. Health system adaptation requires equitably considering the needs of individuals managing multiple chronic conditions. Key factors to address include patient-provider relationships, improved referral systems, accessibility and availability of specialists, and financial assistance.

Self-regulatory coping among community dwelling older adults with multiple chronic conditions

Objectives

Many older adults with multiple chronic conditions (MCC) frequently experience hospitalizations, functional limitations, and poor quality of life. Outcomes may be improved by promoting self-regulation, which may individuals respond to health threats and manage their health conditions. The aim of this study was to describe self-regulatory coping among older adults with MCC.

Methods

A qualitative descriptive study using semi-structured interviews and content analysis and guided by the Common-Sense Self-Regulation Model. Seventeen community-dwelling older adults with two or more chronic conditions participated in our study.

Results

Three themes were developed from the analysis: (1) "I don't think about it unless something happens": coping in the absence of a health event, (2) "doing what I am supposed to do": coping during a health event, and (3) "How do I know if what I did works?": appraisal of coping success.

Discussion

Self-regulatory coping was influenced by individual beliefs and experiences (illness representations), context, self-efficacy and availability of support and resources to cope with MCC. These findings suggest implications for clinical practice and future self-regulation interventions for older adults with MCC.

Evaluating Barriers to Viral Suppression among People with HIV in Santiago, Dominican Republic

The Dominican Republic (DR) has the second-highest prevalence of HIV infection in the Caribbean, but viral suppression and treatment adherence are not well understood. We conducted a cross-sectional study among people living with HIV/AIDS(PLWHA) to fill in the knowledge gap. Questionnaire was used to collect demographic data, antiretroviral therapy (ART) adherence, and barriers and facilitators to HIV care. Viral load and other clinical information were extracted through chart reviews. Descriptive analyzes and logistic regression were conducted to explore factors associated with non-viral suppression and imperfect ART adherence. Of 193 PLWHA 83.9% were virally suppressed. Those that were non-virally suppressed were more likely of being male (odds ratio [OR]: 2.55, 95% confidence interval [CI]: 1.17-5.58) and less likely of being unemployed (OR: 0.28, 95% CI: 0.08-0.96). However, being male (OR: 0.78, 95% CI:0.40-1.53) and unemployed (OR: 0.28, 95% CI:0. 08-1.21) were less likely to report imperfect adherence. Tailored interventions are needed to improve adherence and viral suppression in DR.

"If They Give Their Mind to HIV, They Don't Last as Long": An Explanatory Model of HIV Infection in a Limited-Resource Setting Informs Person-Centered Care

Explanatory models describe individuals’ perceptions of their illness experiences, which can guide culturally relevant care. We constructed an explanatory model of the experience of living with human immunodeficiency virus (HIV) in the Dominican Republic. Following qualitative descriptive methodology, we conducted interviews in Spanish using a semi-structured interview guide developed using Kleinman’s explanatory model framework. Two bilingual researchers coded interview transcripts following conventional content analysis. We used deductive codes from Kleinman’s framework and inductive codes external to the framework to construct the codebook. We arranged codes by shared meaning into categories and constructed themes that reflected shared findings from inductive categories and deductive codes. Twenty-six persons living with HIV participated. They provided rich descriptions of their experiences represented by four cross-cutting themes, which informed the explanatory model. By incorporating this in-depth understanding of patients’ illness experiences into care delivery, nurses can cultivate culturally meaningful and trusting patient-centered partnerships that improve health.

'There are no other options for us because of who we are': employment and retention in care among gay and bisexual men and transgender women living with HIV in Guatemala

The purpose of this study was to improve understanding of the relationship between employment and retention in HIV care among gay and bisexual men and transgender women in Guatemala. We interviewed gay and bisexual men (n = 18) and transgender women (n = 9) receiving care at HIV clinics in three Guatemalan cities. Thematic coding and narrative analysis were used to describe employment experiences and identify employment factors that enabled or hindered retention within the broader context of participants' lives. Employment types ranged from formal, salaried positions to informal jobs; several participants were unemployed. Intersecting stigma related to HIV status, sexual orientation and gender identity reduced participants' ability to find and maintain stable, adequately compensated work. Job opportunities were particularly limited for transgender women due to discrimination related to gender identity. Among gay and bisexual men, discrimination related to HIV was the most salient barrier to employment. Three main employment-related determinants of retention were identified: work schedule, relationships with employers, and income. HIV care and treatment services should be strategically located and have flexible hours tailored to the employment schedules and needs of key populations living with HIV. Social protection programmes are needed to foster quality employment opportunities that facilitate attendance at HIV care appointments.

The 'normality' of living as a gay serodiscordant couple in Sydney, Australia

Serodiscordant couples are often understood through a discourse of HIV-risk or researched in terms of the psychological stressors they face. However, due to antiretroviral treatments people living with HIV can achieve undetectable viral loads, which not only make them non-infectious to partners, but allow them to think of their lives and relationships as safe and viable. These realisations mean that serodiscordant couples often embrace an HIV 'normalisation' discourse. In this article, we argue that this discourse of HIV 'normalisation' can overlook the more nuanced complexity of issues still faced by couples today, which reveal how their experiences of 'normal' are sometimes challenged and are not necessarily 'normal'. Utilising semi-structured interviews with 21 gay men in serodiscordant relationships in Sydney, Australia, we draw on the concept of 'home' life to explore how men engage with discourses of normalisation to describe and enact their relationships. We argue that although HIV is managed well enough to be insignificant in the context of home life, experiences or anticipation of stigma in public often remind couples that they are yet to be considered 'normal' socially.

"It Was as Though My Spirit Left, Like They Killed Me": The Disruptive Impact of an HIV-Positive Diagnosis among Women in the Dominican Republic

An HIV diagnosis may be associated with severe emotional and psychological distress, which can contribute to delays in care or poor self-management. Few studies have explored the emotional, psychological, and psychosocial impacts of an HIV diagnosis on women in low-resource settings. We conducted in-depth interviews with 30 women living with HIV in the Dominican Republic. Interviews were audio-recorded, transcribed, and analyzed using the biographical disruption framework. Three disruption phases emerged (impacts of a diagnosis, postdiagnosis turning points, and integration). Nearly all respondents described the news as deeply distressful and feelings of depression and loss of self-worth were common. Several reported struggling with the decision to disclose—worrying about stigma. Postdiagnosis turning points consisted of a focus on survival and motherhood; social support (family members, friends, HIV community) promoted integration. The findings suggest a need for psychological resources and social support interventions to mitigate the negative impacts of an HIV diagnosis.

Contextualizing Experiences of Diabetes-Related Stress in Rural Dominican Republic

Type 2 diabetes (T2D) is changing the burden of disease across Latin America. In this formative, qualitative study, we explored experiences of T2D diagnosis and management among adults in rural Dominican Republic. We conducted 28 in-depth interviews (12 men, 16 women) and used inductive analysis to explore the emotional burden of T2D and identify coping strategies. We found that stress relating to T2D began at diagnosis and persisted throughout management. Stress was produced by concerns about healthy food and medication access, fears about illness-induced injury, and the cyclical process of experiencing stress. Participants identified diabetes care and free medication services as external stress-reducers. Internally, participants' mitigated stress by not thinking about diabetes (" no dar mente"). Our study highlights the importance of a contextualized understanding of diabetes-related stress and the need for individual, clinic, and community-level interventions to reduce stressors and improve health outcomes among adults with T2D.