Women living with HIV/AIDS: the dual challenge of being a patient and caregiver

Labor Pains: Work-Related Barriers to Access to Health Care for People Living with HIV in Hyderabad, India

To explore themes regarding work-related barriers to access to health care, we conducted 32 interviews, 16 with third gender people and 16 with cisgender women, all of whom were all living with HIV in Hyderabad, India. Most respondents were members of Dalit castes and had been living with HIV for several years at the time of the interview. Using thematic content analysis, interviews were coded by two researchers using a social determinants of health conceptual framework. Themes highlighted in this study include the burden of taking time off from work, the loss of pay associated with missing work, and the interruption of gendered care work responsibilities that respondents faced when seeking treatment. Findings from this study support the claim that equitable work policies and practices for marginalized laborers can increase access to medical care for people living with HIV.

Factors associated with caregiver compliance to an HIV disclosure intervention and its effect on HIV and mental health outcomes among children living with HIV: post-hoc instrumental variable-based analysis of a cluster randomized trial in Eldoret, Kenya

Background

The HADITHI study is a cluster-randomized trial of children living with HIV and their caregivers in Kenya that aimed to increase rates of caregiver disclosure of their child's HIV status, encourage earlier status disclosure, and improve pediatric mental health and HIV outcomes. This analysis identified characteristics predicting caregiver non-responsiveness and compared outcomes among children based on disclosure status.

Methods

A penalized logistic regression model with lasso regularization identified the most important predictors of disclosure. The two-stage least squares instrumental variable approach was used to assess outcomes accounting for non-compliance to disclosure.

Results

Caregiver non-isolation and shorter time on antiretroviral therapy were predictive of HIV status disclosure. There were no statistically significant differences found in CD4 percentage, depression status, or mental and emotional status based on disclosure status up to 24 months-post intervention.

Conclusion

These findings have implications for specialists seeking to tailor disclosure interventions to improve caregiver-child dyad responsiveness.

‘The spiral just keeps on going’: Cascading health and social issues for women living and aging with HIV

Background:

There has been limited qualitative inquiry aimed at understanding the gendered and unique experiences of women living with HIV in high-income countries. In Australia, the relatively small number of women living with HIV means they have been largely overlooked in social, clinical, and policy representations of HIV over time.

Objectives:

To explore the experiences of women living long-term and aging with HIV, to understand the complex intersections between their health and social trajectories.

Methods:

Data were collected as part of Living Positive in Queensland, a longitudinal qualitative study of the experiences of living long-term and aging of people living with HIV in Queensland, Australia. This study analysed data from three annual, semi-structured interviews with the 11 female participants.

Results:

Women negotiated gendered roles and identities as they grappled with ongoing and intertwined health and psychosocial challenges over their life course. Development of co-morbidities, experiences of stigma, gendered social roles, financial precarity, and limited social support amplified the challenges of living with HIV and cumulatively impacted women’s health and wellbeing as they aged with HIV.

Conclusion:

The health and wellbeing of women living with HIV are adversely impacted by intersecting complex health issues, HIV-related stigma, gendered identities, social disadvantage, and aging. Greater attention to the unique needs of women living with HIV is necessary to reduce the prevalence of psychological distress, financial stress, and vulnerability to social isolation which, in turn, lead to poorer health.

Enduring stigma and precarity: A review of qualitative research examining the experiences of women living with HIV in high income countries over two decades

The lived experience of HIV for women remains poorly understood. In particular, there has been little attention to the consequences for women living with HIV (WLHIV) of changing social, epidemiological, biomedical and policy contexts, or to the implications of long-term treatment and aging for the current generation of HIV-positive women. We reviewed qualitative research with WLHIV in selected high-income countries (Australia, Canada, New Zealand, the UK and the USA) to identify the most prevalent experiences of HIV for women and trends over time. Our synthesis highlights the relative consistency of experiences of a diverse sample of WLHIV, particularly the enduring prevalence of gendered HIV-related stigma, sociostructural barriers to healthcare and support, and negative encounters with health professionals. We also identified gaps in knowledge. Understanding women's experiences, particularly their changing needs and strategies for coping as they live long-term with HIV, is key to effective support and services for WLHIV.

Time of HIV diagnosis, CD4 count and viral load at antenatal care start and delivery in South Africa

Background

Despite the success of prevention of mother to child transmission (PMTCT) program in South Africa, the 30% HIV prevalence among women of childbearing age requires the PMTCT program to be maximally efficient to sustain gains in the prevention of vertical HIV transmission. We aimed to determine the immunologic and virologic status at entry into antenatal care (ANC) and at childbirth among HIV positive women who conceived under the CD4<500 cells/μl antiretroviral therapy (ART) eligibility threshold and universal test and treat (UTT) policies in the Gauteng province of South Africa.

Method

We conducted a retrospective cohort study of 692 HIV positive adult (>18 years) postpartum women who gave birth between September 2016 and December 2017. Demographic, viral load (VL) and CD4 data at ANC start (3–9 months before delivery) and delivery (3 months before/after) were obtained from medical records of consenting women. We compared CD4≥500 cell/μl and viral load (VL) suppression (<400 copes/ml) rates at ANC start and delivery among women with a pre-pregnancy ART, women known HIV positive but with in-pregnancy ART and newly diagnosed women with in-pregnancy ART. Predictors of having a high CD4 and suppressed VL were assessed by log-binomial regression.

Results

Of the 692 participants, 394 (57.0%) had CD4 data and 326 (47.1%) had VL data. Overall women with a pre-pregnancy ART were more likely to start ANC with CD4 count≥500 cell/μl (46.3% vs 24.8%, adjusted risk ratio (aRR) = 1.9; 95% confidence interval (95% CI): 1.4–2.5), compared to newly diagnosed women. This difference was no longer apparent at the time of delivery (aRR 1.2 95% CI: 0.4–3.7). Similarly, viral suppression at delivery was higher among women with pre-pregnancy ART (87.2% vs 69.3%, aRR 1.3, 95% CI: 1.1–1.6) as compared to the newly diagnosed women. Viral suppression rate among newly diagnosed women increased substantially by the time of delivery from 43.5% to 69.3% (p = 0.001).

Conclusion

These results show that pre-pregnancy ART improves immunologic and virologic control during pregnancy and call for renewed efforts in HIV testing, linkage to ART and viral monitoring.

The relationship between stigma and a rehabilitation framework [international classification of functioning, disability and health (ICF)]: three case studies of women living with HIV in Lusaka, Zambia

PURPOSE

To explore how the International Classification of Functioning, Disability and Health, a rehabilitation framework, can provide a holistic understanding of stigma experiences of three women living with human immunodeficiency virus in Lusaka, Zambia.

METHODS

A secondary analysis of three cases by drawing on interview transcripts collected as part of a larger longitudinal study with eighteen women living with the virus. The interview tool used the rehabilitation framework to ask questions about the impact of the virus on the body, daily activities, social participation and the future. Vignettes were produced for each of the eighteen women including information on stigma and the rehabilitation framework. Three case studies were developed from women who provided comprehensive accounts of stigma and the International Classification of Functioning, Disability and Health.

RESULTS

Stigma experiences aligned well with three dimensions of the International Classification of Functioning, Disability and Health: participation restrictions, environmental and personal factors. These domains were used to understand stigma in three forms (i.e. enacted, self and structural stigma) as experienced by these women.

CONCLUSIONS

More research is needed to ascertain how stigma and rehabilitation are related in other environments and populations and to explore how to mitigate stigma within the rehabilitation context.IMPLICATIONS FOR REHABILITATIONRehabilitation professionals deal with aspects of stigma and discrimination in their clinical work and this analysis offers a way to consider HIV-related stigma within rehabilitation in an organized and theoretically-informed way.The insights from this study are important for the field of HIV and for advancing understanding of the complexities of stigma in the context of rehabilitation more broadly.This analysis offers guidance to rehabilitation providers about the nuanced and multi-faceted ways that stigma can occur in the context of rehabilitation, including within their own clinical practice.

Structural equation modeling analysis of social support, coping strategies, depression and suicidal ideation among people living with HIV/AIDS in Changsha, China

INTRODUCTION

People living with HIV/AIDS (PLWHA) have a higher rate of suicide compared to the general population. Psychosocial factors closely correlate with suicidal ideation and it is essential to explain the relationships between related factors among PLWHA.

OBJECTIVES

To establish a structural equation model and examine direct and indirect effects of social support, coping strategy, depression symptoms and suicidal ideation among PLWHA.

PATIENTS AND METHODS

A total of 504 PLWHA completed a set of questionnaires in the HIV clinic of Changsha Infectious Disease Hospital between December 2015 and January 2016.

RESULTS

Among the 504 respondents, a total of 27.2% (n=137) had experienced suicidal ideation in their lifetime. The goodness of fit for the two structural equations model was highly satisfactory. Depression symptoms had a significant direct impact on suicidal ideation (β ₁=0.401, β ₂=0.422), while problem-focused coping (β=-0.067), emotion-focused coping (β=-0.081) and social support (β=-0.137) had a significant indirect effect with suicidal ideation via depression symptoms. Factors of total effects were ranked from large to small as follows: depression, social support, emotion-focused coping and problem-focused coping.

CONCLUSION

Findings provide more understanding of direct and indirect associations between variables, suggesting that depression screening services, and the strengthening of social support and psychological care services among PLWHA can potentially prevent suicide.

Women Living with HIV/AIDS

The main aim of this review article is to outline the factors linked to vulnerability of women to HIV infection and to understand the challenges and possible management of HIV among women. The review is a theoretical endeavour to understand women’s experiences of living with HIV. This review primarily focuses on studies in the Indian set-up, but to further substantiate the arguments and describe the relevant concepts it also takes into account literature from other cultures.

On the basis of studies included in this article, it can be surmised that women are more susceptible to HIV due to cultural barriers, health vulnerabilities and social structures. They show less awareness about the treatment facilities, prevention strategies and perceived risk of infection. Women have to face numerous challenges after the infection, such as lack of social support, a higher level of stigma and discrimination, decreased quality of life, mental health issues and adverse coping. To prevent the spread of HIV among women as well as men, it is necessary to plan strategies which deal with empowerment of women, education and awareness regarding the vulnerabilities and knowledge and challenges of HIV infection. There is also a need to address the management of HIV among the infected and even those at risk. This article describes the possible interventions based on existing literature. The review also attempts to suggest certain future directions for the research.

"HIV Changed My Life Forever": An Illustrative Case of a Sub-Saharan African Migrant Woman Living with HIV in Belgium

Living with HIV and AIDS changes everything for people diagnosed with HIV and it can be the most difficult experience in life. Like most people who have chronic diseases, these individuals have to deal with living a normal and quality life. Globally, more women (51%) than men are HIV positive. The main aim of this paper was to describe a sub-Saharan African migrant woman’s lived experience, and also to use the individual’s story to raise questions about the larger context after a HIV diagnosis. A qualitative study consisting of a personal story of a HIV-infected sub-Saharan African living in Belgium was conducted. Data were analysed using thematic analysis. The main themes that emerged from the data included relational risks, personal transformation and the search for normality, anxiety, depression, fear of stigma, societal gender norms, and support. The participant reported that marriage was no guarantee of staying HIV-free, especially in a male-dominant culture. This case further illustrates that married and unmarried African women are often at high risk of HIV and also informs us how HIV could spread, not only because of cultural practices but also because of individual behaviour and responses to everyday life situations. The participant also emphasized that she is faced with physical and mental health problems that are typical of people living with HIV. The vulnerability of sub-Saharan African women to HIV infection and their precarious health-related environments wherever they happen to be is further elucidated by this case.

Prevalence and correlates of psychological distress of middle-aged and older women living with HIV

The aims of this study were to examine the prevalence and correlates of psychological distress among older women living with HIV in comparison to their male counterparts and younger women and to identify the sociodemographic and disease-related factors associated with psychological distress. The sample consisted of 508 HIV-infected patients (65 older women, 323 women aged below 50 years, and 120 older men) recruited from 10 Portuguese hospitals. Data regarding psychological distress were collected using the Brief Symptom Inventory (BSI). Seven older women (10.8%), eight older men (6.7%), and 61 younger women (18.9%) reported a T-score ≥ 63 for global severity index (GSI), indicative of a need for further psychological evaluation. Overall, younger women reported significantly higher psychological distress than older men. The odds of having clinically significant psychological distress score were significantly lower for older women reporting sexual transmission, while for younger women, having other co-infections was a significant correlate of higher psychological distress. Younger women were 2.67 (95% CI: 1.22-5.84) times more likely to report psychological distress than were older men. The odds were not significantly different from older women. This study shows that older women do not differ substantially from younger women and older men in terms of psychological distress. The results reinforce, however, that mental health interventions should be tailored to reflect individuals' circumstances as well as developmental contexts. Moreover, they draw attention to the importance of examining resilience characteristics in older adults to understand the mechanisms behind 'successful ageing' while living with HIV.

PERCEPTIONS OF STIGMA AND DISCRIMINATION IN HEALTH CARE SETTINGS TOWARDS SUB-SAHARAN AFRICAN MIGRANT WOMEN LIVING WITH HIV/AIDS IN BELGIUM: A QUALITATIVE STUDY

Stigma and discrimination within health care settings remain a public health challenge across diverse cultural environments and may have deleterious effects on mental and physical health. This study explores the causes, forms and consequences of HIV-related stigma and discrimination among migrant sub-Saharan African women living with HIV in Belgium. A qualitative study was conducted with 44 HIV-positive sub-Saharan African migrant women between April 2013 and December 2014 in health care settings in Belgium. Data were analysed using thematic content analysis. Twenty-five of the women reported overt stigma and discrimination and fifteen reported witnessing behaviours that they perceived to be stigmatizing and discriminatory in health care settings. The themes that emerged as to the causes of stigma and discrimination were: public perceptions of migrants and HIV, fear of contamination and institutional policies on HIV management. Reported forms of stigma and discrimination included: delayed or denied care, excessive precautions, blame and humiliation. The consequences of stigma and discrimination were: emotional stress, inconsistent health-care-seeking behaviour and non-disclosure to non-HIV treating personnel. Stigma and discrimination in health care settings towards people with HIV, and more specifically towards HIV-positive sub-Saharan African migrant women, impedes sustainable preventive measures. Specialized education and training programmes for non-HIV health care providers require in-depth investigation.

‘We are Not Fresh’: HIV-Positive Women Talk of Their Experience of Living with Their ‘Spoiled Identity’

Women have been identified as being at greater risk than men in South Africa's growing HIV epidemic. Stigma contributes to the epidemic, as it makes HIV-positive individuals reluctant to become identified and seek appropriate care. The purpose of this study is to begin to explore how women experience and deal with AIDS stigma under conditions where they have little formal support. In-depth, narrative interviews were conducted with ten HIV-positive women, living in a poor, black township in Cape Town. The study used both social constructionist and psychoanalytic theory to understand the impact that their ‘spoiled identity’ had on the emotional lives of these women. The study elicited women's narratives as they talked about their experience of living with a ‘spoiled identity’. The analysis suggested that the women drew on negative social discourses around HIV, which were then internalised, to become part of the self. However, the narratives also indicated the women's resistance to their stigmatised identity. The narratives illustrated their attempts to fend off the ‘spoiled identity’ by splitting off these bad representations and projecting them outside of themselves.

How Much Should We Expect? Family Caregiving of AIDS Patients in Rural Uganda

The aim of this study was to measure the burden of care for family caregivers of AIDS patients. A cross-sectional exploratory design was used to describe the care experiences of family caregivers of AIDS care recipients. A questionnaire was used to interview 120 family caregivers of AIDS patients from four rural areas in western Uganda. The questions asked were related to 12 domains of family caregiving. Care burden scores of caregivers were calculated. It was found that care burden scores were high in all domains except those regarding relationships within the families and substance abuse. Serious work overload and low health status were reported. The high burden of caregiving puts family caregivers at risk for decreased health status and increased social isolation and depression.

'Are we allowed to disclose?': a healthcare team's experiences of talking with children and adolescents about their HIV status

BACKGROUND

Talking with a child about their HIV status is a complex, emotionally laden and difficult task for caregivers and healthcare providers. Disclosure is an important process which may have psychosocial and health benefits. Despite existing guidelines and materials, disclosure does not always happen for various reasons.

OBJECTIVE

This qualitative study explored a healthcare team's perspectives and experiences about disclosure practices.

METHODS

Three focus groups were conducted with a total of 23 healthcare providers at a paediatric clinic in South Africa. The data were analysed using principles of thematic analysis.

RESULTS

Results confirm the complexity of the disclosure process and highlight confusion, hesitancy and ethical dilemmas regarding disclosure practices. Tensions were noted within the team which seem linked to professional hierarchies. Counsellors and nurses preferred an indirect approach of encouraging caregivers to disclose to their children and providing psychosocial support, while doctors tended to become more directly involved in disclosing to children out of a sense of duty, legal responsibilities and knowledge of the child's rights.

DISCUSSION AND CONCLUSIONS

This study demonstrates how the complexities of disclosure with children and adolescents bring about additional challenges for healthcare teams. The legal and ethical implications as well as the roles and responsibilities of healthcare providers with disclosure remain unclear. Several recommendations for practice and policy emerge from this study, related particularly to the need for clarification of disclosure guidelines and legal implications. Implications for the healthcare team are also discussed.

Identifying HIV-Infected Women's Psychosocial Stressors: Findings from a Qualitative Study

To inform future psychosocial interventions for HIV-infected women, five focus groups were conducted with 29 HIV-infected women (72% African-American). Sessions were audio-recorded, transcribed, and coded by two raters. HIV-specific stressors included difficulties with serostatus disclosure, HIV medication adherence, and HIV-related discrimination. Stressors not directly linked to HIV were described as more concerning and included mental health or substance use problems, relationship challenges, caretaking for children or grandchildren, and financial difficulties. Participants suggested that interventions provide social support from other HIV-infected women, consistent case management and social work services, and forums to acquire additional information about HIV and treatment options.

Barriers to health-care and psychological distress among mothers living with HIV in Quebec (Canada)

Health-care providers play a major role in providing good quality care and in preventing psychological distress among mothers living with HIV (MLHIV). The objectives of this study are to explore the impact of health-care services and satisfaction with care providers on psychological distress in MLHIV. One hundred MLHIV were recruited from community and clinical settings in the province of Quebec (Canada). Prevalence estimation of clinical psychological distress and univariate and multivariable logistic regression models were performed to predict clinical psychological distress. Forty-five percent of the participants reported clinical psychological distress. In the multivariable regression, the following variables were significantly associated with psychological distress while controlling for sociodemographic variables: resilience, quality of communication with the care providers, resources, and HIV disclosure concerns. The multivariate results support the key role of personal, structural, and medical resources in understanding psychological distress among MLHIV. Interventions that can support the psychological health of MLHIV are discussed.

Intervening on conflict, parental bonds, and sexual risk acts among adolescent children of mothers living with HIV

Objective

In 1993–1994, a psychosocial intervention conducted in New York City significantly improved outcomes for parents living with HIV and their adolescent children over six years. We examine if the intervention benefits are similar for adolescents of mothers living with HIV (MLH) in 2004–2005 in Los Angeles when MLH’s survival had increased substantially.

Methods

Adolescents of MLH in Los Angeles (N = 256) aged 12–20 years old were randomized with their MLH to either: 1) a standard care condition (n = 120 adolescent-MLH dyads); or 2) an intervention condition consisting of small group activities to build coping skills (n = 136 adolescent-MLH dyads, 78% attended the intervention). At 18 months, 94.7% of adolescents were reassessed. Longitudinal structural equation modeling examined if intervention participation impacted adolescents’ relationships with parents and their sexual risk behaviors.

Results

Compared to the standard care, adolescents in the intervention condition reported significantly more positive family bonds 18 months later. Greater participation by MLH predicted fewer family conflicts, and was indirectly associated with less adolescent sexual risk behavior at the 18 month follow-up assessment. Anticipated developmental patterns were observed - sexual risk acts increased with age. Reports were also consistent with anticipated gender roles; girls reported better bonds with their mothers at 18 months, compared to boys.

Conclusions

Adolescents of MLH have better bonds with their mothers as a function of participating in a coping skills intervention and reduced sexual risk-taking as a function of MLH intervention involvement.

Understanding the promise: considering the experiences of women living with HIV to maximize effectiveness of HIV prevention technologies

BACKGROUND

The United States' response to HIV was designed primarily to meet the needs of single men without dependent children and its prevention strategies focused primarily on individual behavior change with little attention to the social, cultural, and economic factors fueling HIV risk, especially among indigent and marginalized women. In 2012, the President's Advisory Council called for an updating of the National HIV/AIDS Strategy's Implementation Plan to "achieve specific, targeted and measurable goals for reducing HIV incidence and … improving health care access and health outcomes for women living with HIV."

OUTCOME MEASURES

Women living with HIV and those at greatest risk of HIV generally live side by side in the same communities and under the same conditions, separated in status only by a positive HIV test and its consequences. Thus, women openly living with HIV constitute an identifiable and accessible source of first-hand information regarding the barriers that keep women out of HIV prevention and care. Their insights, rooted in lived experience, can vitally inform the development of realistic HIV prevention goals and strategies for the successful integration of HIV prevention into the services already accessed by high-risk women. Their expertise, however, is largely untapped.

CONCLUSIONS

In this article, women living with HIV summarize the substantial deficits that exist with regard to woman-focused HIV prevention efforts nationally and the policy and practice changes needed to reduce the domestic impact of the HIV epidemic on women and girls. They also outline opportunities for movement in this direction as implementation of the National HIV/AIDS Strategy proceeds.

Cumulative effects of HIV illness and caring for children orphaned by AIDS on anxiety symptoms among adults caring for children in HIV-endemic South Africa

Adults caring for children in HIV-endemic communities are at risk for poor psychological outcomes. However, we still have a limited understanding of how various HIV impacts--including caregiver's own HIV illness, responsibilities of caring for a child orphaned by AIDS, or both--affect psychological outcomes among caregivers. Furthermore, few studies have explored the relationship between stigma, HIV, and psychological outcomes among caregivers of children in HIV-endemic communities. A cross-sectional survey conducted from 2009 to 2010 assessed anxiety among 2477 caregivers of children in HIV-endemic South Africa. Chi-square tested differences in anxiety among caregivers living with HIV, caregivers of a child orphaned by AIDS, and caregivers affected with both conditions. Multivariate logistic regressions identified whether the relationship between HIV impacts and anxiety remained after controlling for socio-demographic co-factors. Mediation analysis tested the relationship between stigma, HIV, and anxiety. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were two and a half times greater among caregivers living with HIV compared to nonaffected caregivers. The odds of meeting threshold criteria for clinically relevant anxiety symptoms were greatest among caregivers living with HIV and caring for a child orphaned by AIDS. Exposure to AIDS-related stigma partially mediated the relationship between HIV and anxiety. Interventions are needed to address caregiver psychological health, particularly among caregivers affected with both conditions of living with HIV and caring for a child orphaned by AIDS.

Pregnant women living with HIV (WLH) supported at clinics by peer WLH: a cluster randomized controlled trial

Throughout Africa, Peer Mentors who are women living with HIV (WLH) are supporting pregnant WLH at antenatal and primary healthcare clinics (McColl in BMJ 344:e1590, 2012). We evaluate a program using this intervention strategy at 1.5 months post-birth. In a cluster randomized controlled trial in KwaZulu-Natal, South Africa, eight clinics were randomized for their WLH to receive either: standard care (SC), based on national guidelines to prevent mother-to-child transmission (4 clinics; n = 656 WLH); or an enhanced intervention (EI; 4 clinics; n = 544 WLH). The EI consisted of four antenatal and four postnatal small group sessions led by Peer Mentors, in addition to SC. WLH were recruited during pregnancy and 70 % were reassessed at 1.5 months post-birth. EI's effect was ascertained on 16 measures of maternal and infant well-being using random effects regressions to control for clinic clustering. A binomial test for correlated outcomes evaluated EI's overall effectiveness. Among EI WLH reassessed, 87 % attended at least one intervention session (mean 4.1, SD 2.0). Significant overall benefits were found in EI compared to SC using the binomial test. However, it is important to note that EI WLH were significantly less likely to adhere to ARV during pregnancy compared to SC. Secondarily, compared to SC, EI WLH were more likely to ask partners to test for HIV, better protected their infants from HIV transmission, and were less likely to have depressed mood and stunted infants. Adherence to clinic intervention groups was low, yet, there were benefits for maternal and infant health at 1.5 months post-birth.

Individual and contextual factors of influence on adherence to antiretrovirals among people attending public clinics in Rio de Janeiro, Brazil

BACKGROUND

There are inconsistencies in the determinants of adherence to antiretrovirals (ARVs) across settings as well as a lack of studies that take into consideration factors beyond the individual level. This makes it necessary to examine factors holistically in multiple settings and populations while taking into consideration the particularities of each context, in order to understand the patterns of ARV adherence. This research explored ARV adherence and individual, relational and environmental-structural factors.

METHODS

A cross-sectional survey was conducted from August 2008 through July 2009 among participants currently on ARVs recruited from 6 public health clinics, selected to maximize diversity in terms of caseload and location, representing the range of clinics within Rio de Janeiro city, Brazil. Multivariate logistic regression analysis was used to assess the association between our multilevel factors with ARV adherence among participants with complete cases (n = 632).

RESULTS

Eighty-four percent of respondents reported adherence to all of their ARV doses in the last 4 days. Of the socio-demographic variables, those who had one child were positively associated with adherence (AOR 2.29 CI [1.33-3.94]). On the relational level, those with high social support (AOR 2.85 CI [1.50-5.41]) were positively associated with adherence to ARVs. On the environmental-structural level, we found gender was significant with women negatively associated with adherence to ARVs (AOR 0.58 CI [0.38-0.88]) while those with a high asset index (AOR 2.47 CI [1.79-3.40]) were positively associated with adherence to ARVs.

CONCLUSIONS

This research highlights the importance of examining the multiple levels of influence on ARV adherence. Intervention research in lower and middle-income settings should address and evaluate the impact of attending to both gender and economic inequalities to improve ARV adherence, as well as relational areas such as the provision of social support.

The impact of social context on self-management in women living with HIV

HIV self-management is central to the health of people living with HIV and is comprised of the daily tasks individuals employ to manage their illness. Women living with HIV are confronted with social context vulnerabilities that impede their ability to conduct HIV self-management behaviors, including demanding social roles, poverty, homelessness, decreased social capital, and limited access to health care. We examined the relationship between these vulnerabilities and HIV self-management in a cross-sectional secondary analysis of 260 women living with HIV from two U.S. sites. All social context variables were assessed using validated self-report scales. HIV Self-Management was assessed using the HIV Self-Management Scale that measures daily health practices, HIV social support, and the chronic nature of HIV. Data were analyzed using appropriate descriptive statistics and multivariable regression. Mean age was 46 years and 65% of participants were African-American. Results indicated that social context variables, particularly social capital, significantly predicted all domains of HIV self-management including daily health practices (F = 5.40, adjusted R(2) = 0.27, p < 0.01), HIV social support (F = 4.50, adjusted R(2) = 0.22, p < 0.01), and accepting the chronic nature of HIV (F = 5.57, adjusted R(2) = 0.27, p < 0.01). We found evidence to support the influence of the traditional social roles of mother and employee on the daily health practices and the chronic nature of HIV domains of HIV self-management. Our data support the idea that women's social context influences their HIV self-management behavior. While social context has been previously identified as important, our data provide new evidence on which aspects of social context might be important targets of self-management interventions for women living with HIV. Working to improve social capital and to incorporate social roles into the daily health practices of women living with HIV may improve the health of this population.

Despondency among HIV-positive older men and women in Uganda

Forty people over 60 years of age took part in longitudinal research over the course of a year on the impact of the HIV epidemic in southern Uganda. In this paper we focus mainly on the data from 26 of the 40 who were HIV-positive. While we observed that feelings of depression were frequently experienced by many of the people in our study, the state of ‘being depressed’ was not constant. Participants regularly expressed economic frustration (because of a lack of money to buy food and other commodities including sugar and soap); medical problems (including those related to HIV) as well as old age, the burden of dependents (including concerns about school fees for grandchildren), feelings of sadness and isolation, and a lack of support from others, as well as stigma, whether real or perceived. However, while worries, sorrow and despondent thoughts were reported in many of the interviews across the study, moods fluctuated moving from happiness and hope, to sadness and despair, from month to month. Concerns regarding the psychological wellbeing amongst older people, including those living with HIV and older carers in Uganda deserve greater attention.

Measuring HIV self-management in women living with HIV/AIDS: a psychometric evaluation study of the HIV Self-management Scale

OBJECTIVE

To develop and validate the HIV Self-management Scale for women, a new measure of HIV self-management, defined as the day-to-day decisions that individuals make to manage their illness.

METHODS

The development and validation of the scale was undertaken in 3 phases: focus groups, expert review, and psychometric evaluation. Focus groups identified items describing the process and context of self-management in women living with HIV/AIDS (WLHA). Items were refined using expert review and were then administered to WLHA in 2 sites in the United States (n = 260). Validity of the scale was assessed through factor analyses, model fit statistics, reliability testing, and convergent and discriminate validity.

RESULTS

The final scale consists of 3 domains with 20 items describing the construct of HIV self-management. Daily self-management health practices, social support and HIV self-management, and chronicity of HIV self-management comprise the 3 domains. These domains explained 48.6% of the total variance in the scale. The item mean scores ranged from 1.7 to 2.8, and each domain demonstrated acceptable reliability (0.72-0.86) and stability (0.61-0.85).

CONCLUSIONS

Self-management is critical for WLHA, who constitute over 50% of people living with HIV/AIDS (PLWHA) and have poorer health outcomes than their male counterparts. Methods to assess the self-management behavior of WLHA are needed to enhance their health and wellbeing. Presently, no scales exist to measure HIV self-management. Our new 20-item HIV Self-management Scale is a valid and reliable measure of HIV self-management in this population. Differences in aspects of self-management may be related to social roles and community resources, and interventions targeting these factors may decrease morbidity in WLHA.

HIV status and gender: a brief report from heterosexual couples in Thailand

Although the impact of HIV falls on both partners of a married couple, the burden of stress may not be necessarily shared evenly. The researchers in this study examined the relations among HIV status, gender, and depressive symptoms among 152 married or cohabitating couples living with HIV in the northern and northeastern regions of Thailand. Depressive symptoms were assessed using a 15-item depressive symptom screening test that was developed and used previously in Thailand. Among the 152 couples, 59% were couples in which both members were people living with HIV (seroconcordant; both people living with HIV couples), 28% had only female members with HIV (serodiscordant; females living with HIV couples), and 13% had only male members with HIV (serodiscordant; males living with HIV couples). The prevalence of depressive symptoms between seroconcordant and serodiscordant groups was similar. However, females living with HIV reported significantly higher levels of depressive symptoms, regardless of their partners' HIV status. Future prevention programs focusing on serodiscordant couples should be planned to target HIV risk, as well as emphasis on mental health, with a particular focus on women's increased susceptibility to negative mental health outcomes.

Impact of paediatric human immunodeficiency virus infection on children's and caregivers' daily functioning and well-being: a qualitative study

BACKGROUND

Human immunodeficiency virus (HIV) infection impacts not only upon the physical health of affected children, but also their psychosocial functions, family relationships and economical status. Caregivers are confronted with complex challenges related to the physical, emotional and financial demands of raising these children. The purpose of this study was to enhance our understanding of the impact of HIV disease on both children's and caregivers' well-being, using a qualitative inquiry approach.

METHODS

A total of 35 primary caregivers of HIV-infected children participated in in-depth interviews. The issues discussed included the major negative impacts on children's daily functioning and well-being, and the perceived caregiver/parental burden. Participants included parents (40%), grandparents (22.8%), other relatives (e.g. uncles, aunts) (34.3%) and one foster parent (2.8%).

RESULTS

Qualitative analysis revealed that the major negative impacts of HIV/AIDS included physical symptoms, school performance and relationship changes. The major negative impacts on caregivers' well-being included acceptance of the diagnosis, dealing with the financial burden and keeping the diagnosis private.

CONCLUSIONS

Approaches are needed to address these challenges by enhancing families' coping skills and building supportive networks.

'Dying from' to 'living with': framing institutions and the coping processes of African American women living with HIV/AIDS

How do HIV-positive individuals transition from believing and behaving as though they have a 'death sentence' to interpreting and coping with HIV as a chronic but manageable illness? Using interview data collected from 30 HIV-positive African American women beginning in 2005, we reveal how and why interactions with non-profit and government institutions help to explain variation between those who thrive and those who do not following an HIV diagnosis. We argue that 'framing institutions' shape the form and tenor of coping trajectories by offering initial information about one's HIV status, a conceptual framework for understanding what it means to have HIV, language to talk about one's condition, and resources to begin restructuring one's life in the wake of a diagnosis. Ultimately, we highlight how a diverse array of non-profit and government institutions not only play a critical part in helping women cope with HIV but also renegotiate their self-conceptions as black women in the wake of receiving another stigmatizing social marker. In short, organizational ties shape women's movement from beliefs and behaviors that suggest that they are 'dying from' this disease to attitudes and actions consistent with the notion that they can 'live with' HIV.

Perceived stress levels among HIV/AIDS-infected mothers: the role of over-the-counter products

The purpose of this study was to identify correlates of perceived stress levels among 49 HIV/AIDS-infected mothers enrolled in a social services agency that provides HIV/AIDS support services in North Carolina. The author found in an Ordinary Least Squares regression analysis that the CD4 t-cell count, receipt of advice or support from church pastor, annual household income, and employed were all negatively related to seropositive mothers' perceived stress scores. Conversely, the need to have borrowed money from family members or friends to help pay for over-the-counter products like nutritional drinks, vitamins, or minerals was found to be positively related to these scores. The accessibility of these over-the-counter products could not only help to lower seropositive mothers' perceived stress levels but also potentially improve the functioning of their body's immune system. Implications for the Medicaid Program's prescription drug policy that excludes these over-the-counter products and prescription drug representatives are discussed.

Gender and age differences in quality of life and the impact of psychopathological symptoms among HIV-infected patients

The purpose of this study was to determine gender and age differences and interaction effects on the quality of life (QoL) domains in a sample of Portuguese HIV-positive patients, and to examine to what degree psychopathological symptoms are associated with QoL in addition to sociodemographic and clinical variables. The sample consisted of 1191 HIV-positive patients, and measures included the WHOQOL-HIV-Bref and the Brief Symptom Inventory. Controlling for clinical status, there was a significant effect of gender on QoL. Women reported lower scores of Psychological and Spirituality QoL. Younger patients reported higher scores on Physical and Level of Independence domains. Age by gender interactions emerged on all domains of QoL except on the Level of Independence domain. Overall, women over 45 years old showed lower QoL scores. Psychopathological symptoms contributed significantly to the variance of all QoL domains. Gender differences in the association of HIV infection with QoL and psychopathological symptoms seemed to be modulated by age. Understanding gender and age differences (and their interaction) may provide potentially useful information for planning interventions to improve QoL and mental health among people infected with HIV/AIDS, especially among older women.

The relationship between social roles and self-management behavior in women living with HIV/AIDS

BACKGROUND

The social roles that women perform can be complicated and may affect their health. While there is some evidence describing traditional social roles of women, there is little evidence exploring the impact of those roles on how a woman manages a chronic condition. The purpose of this paper is to identify and examine the main social roles of 48 HIV infected women, and to explore how these roles relate to their self-management of HIV/AIDS.

METHODS

Forty-eight HIV infected, adult women were recruited from HIV clinics and AIDS service organizations in Northeast Ohio. All participants participated in one of 12 digitially recorded focus groups. All data were analyzed using qualitative description methodology.

RESULTS

The participants were predominantly middle-aged (mean = 42 years), African American (69%), and single (58%). Analysis revealed six social roles that these women experience and which affect their self-management. These social roles are: Mother/Grandmother, Believer, Advocate, Stigmatized Patient, Pet Owner, and Employee. These roles had both a positive and negative effect on a woman's self-management of her HIV disease and varied by age and time living with HIV.

CONCLUSION

Women living with HIV/AIDS struggle to manage the many daily tasks required to live well with this disease. The social context in which this self-management happens is important, and the various social roles that women perform can facilitate or hinder them from completing these tasks. Healthcare and social service providers should learn about these roles in their individual patients, particularly how these roles can be developed to increase HIV/AIDS self-management.

Parents' disclosure of their HIV infection to their children in the context of the family

We interviewed 33 HIV-infected parents from the HIV Cost and Services Utilization Study (HCSUS), 27 of their minor children, 19 adult children, and 15 caregivers about the process of children learning that their parents were HIV positive. We summarize the retrospective descriptions of parents' disclosure of their HIV status to their children, from the perspective of multiple family members. We analyzed transcripts of these interviews with systematic qualitative methods. Both parents and children reported unplanned disclosure experiences with positive and negative outcomes. Parents sometimes reported that disclosure was not as negative as they feared. However, within-household analysis showed disagreement between parents and children from the same household regarding disclosure outcomes. These findings suggest that disclosure should be addressed within a family context to facilitate communication and children's coping. Parents should consider negative and positive outcomes, unplanned disclosure and children's capacity to adapt after disclosure when deciding whether to disclose.

The Interface between the Family and the Health Care System in the Care of People with HIV/AIDS

Family care experiences of caregivers and care receivers in the context of HIV/AIDS were studied in Mumbai, India, following van Manen’s hermeneutic phenomenological approach. Data were gathered through conversational interviews and were subjected to holistic and highlighting thematic analyses. The findings underscore that interactions with the formal health care system contributed to the essential meaning of participants’ experiences even though the context of care was primarily familial. These interactions included instances of violations of testing and confidentiality guidelines and refusals to provide treatment in private, and some public health centres and the provision of instrumental and affective support by the voluntary sector. The poor quality of care in public sector hospitals serving HIV positive individuals was also described.

The effect of a basic home stimulation programme on the development of young children infected with HIV

AIMS

The human immunodeficiency virus (HIV) potentially causes a significant encephalopathy and resultant developmental delay in infected children. The aim of this study was to determine whether a home-based intervention programme could have an impact on the neurodevelopmental status of children infected with HIV.

METHOD

A longitudinal, randomized, controlled trial was conducted. A total of 122 children aged less than 2 years 6 months were assigned to either a comparison or an experimental group. Children in the experimental group were given a home stimulation programme that was updated every 3 months. The home programme included activities to promote motor, cognitive, and speech and language development. Children in the comparison group received no developmental intervention. Children were assessed by a blinded assessor at baseline, 6 months, and 12 months using the Bayley Scales of Infant Development, 2nd edition.

RESULTS

The children in this study came from poor socioeconomic backgrounds and their nutritional status was suboptimal. The experimental group included 60 children (30 males, 30 females) with a mean age of 18 months (SD 8.1 mo). The comparison group included 62 children (32 males, 30 females) with a mean age 19 months (SD 8.2 mo). Cognitive and motor development were severely affected at baseline, with 52% of the children having severe cognitive delay and 72% having severe motor delay at baseline. Children in the experimental group showed significantly greater improvement in cognitive (p=0.010) and motor (p=0.020) development over time than children in the comparison group.

INTERPRETATION

A home stimulation programme taught to the caregiver can significantly improve cognitive and motor development in young children infected with HIV.

Spiritual well-being, depressive symptoms, and immune status among women living with HIV/AIDS

Spirituality is a resource some HIV-positive women use to cope with HIV, and it also may have positive impact on physical health. This cross-sectional study examined associations of spiritual well-being, with depressive symptoms, and CD4 cell count and percentages among a non-random sample of 129 predominantly African-American HIV-positive women. Significant inverse associations were observed between depressive symptoms and spiritual well-being (r = -.55, p = .0001), and its components, existential well-being (r = -.62, p = .0001) and religious well-being (r = -.36, p = .0001). Significant positive associations were observed between existential well-being and CD4 cell count (r = .19, p < .05) and also between spiritual well-being (r = .24, p < .05), religious well-being (r = .21, p < .05), and existential well-being (r = .22, p < .05) and CD4 cell percentages. In this sample of HIV-positive women, spiritual well-being, existential well-being, and religious well-being accounted for a significant amount of variance in depressive symptoms and CD4 cell percentages, above and beyond that explained by demographic variables, HIV medication adherence, and HIV viral load (log). Depressive symptoms were not significantly associated with CD4 cell counts or percentages. A significant relationship was observed between spiritual/religious practices (prayer/meditation and reading spiritual/religious material) and depressive symptoms. Further research is needed to examine relationships between spirituality and mental and physical health among HIV-positive women.

Association of child care burden and household composition with adherence to highly active antiretroviral therapy in the Women's Interagency HIV Study

Our objective was to describe the association that childcare burden, household composition, and health care utilization have with adherence to highly active antiretroviral therapy (HAART) among women in the United States. The primary outcome was 95% or more adherence to HAART evaluated at 10,916 semiannual visits between October 1998 and March 2006 among 1419 HIV-infected participants enrolled in the Women's Interagency HIV Study. HAART adherence levels of 95% or more were reported at 76% of the semiannual visits. At only 4% of the person-visits did women report either quite a bit or extreme difficulty in caring for child; at 52% of the person-visits women reported at least one child 18 years of age or older living in the household. We found a one-unit increase in the difficulty in caring for children (childcare burden was assessed on a 5-point scale: not difficult [1] to extremely difficult [5]) was associated with a 6% decreased odds of 95% or more HAART adherence (adjusted odds ratio [OR] = 0.94; p = 0.07). Each additional child 18 years of age or less living in the household was associated with an 8% decreased odds of 95% or more adherence (adjusted OR = 0.92, p = 0.03). Both the number and type of adult living in the household, as well as health care utilization were not associated with HAART adherence. Greater child care burden and number of children 18 years old or younger living in household were both inversely associated with HAART adherence. Assessing patients' difficulties in caring for children and household composition are important factors to consider when addressing adherence to HAART.

Burden of depression among impoverished HIV-positive women in Peru

OBJECTIVES

In resource-poor settings, the mental health burden among HIV-positive women is exacerbated by poverty. We sought to describe the extent, risk factors, and experience of depression among impoverished HIV-positive women living in Lima, Peru.

METHODS

This is a case series of 78 HIV-positive women in Lima, Peru. We measured depression, stigma, and social support and performed a multivariable analysis to identify factors associated with depression.

RESULTS

Among 78 HIV-positive patients, 68% were depressed. Depression and suicidal ideation were rarely diagnosed by providers. In multivariable analysis, HIV-related stigma and food scarcity were associated with depression.

CONCLUSIONS

In our cohort of HIV-positive women in Lima, Peru, poverty and socioeconomic vulnerability contributed to depression. Findings highlight the heavy burden of depression in this cohort of poor women and the need to incorporate mental health services as an integral component of HIV care.

HIV-infected mothers' perceptions of uncertainty, stress, depression and social support during HIV viral testing of their infants

To explore relationships between mothers' uncertainty about infant HIV serostatus with stress, distress, depressive symptoms, and social support during infant HIV testing. This prospective longitudinal study of 20 HIV-infected mothers involved a prenatal visit and five postpartum visits clustered around infant HIV viral testing. Maternal uncertainty about infant HIV serostatus significantly decreased over time (p < 0.001). Before testing, uncertainty was inversely related to social support (r = -0.67), and positively related to perceived stress (r = 0.54), interpersonal social conflict (r = 0.57), symptom distress (r = 0.62), and depressive symptoms (r = 0.50); these relationships persisted throughout the infant testing period. Mothers with depressive symptoms during pregnancy demonstrated significantly more uncertainty within a few weeks after birth than mothers without depressive symptoms (p < 0.05). Several weeks after learning their infants were HIV negative, mothers' uncertainty was only associated with social conflict (r = 0.49). Maternal uncertainty about infant HIV status declined significantly over time. There were no changes in perceptions of stress, distress or social support. Mothers with depressive symptoms experienced greater uncertainty about infants' HIV status. Strategies to enhance support and treat depressive symptoms may reduce the uncertainty, stress, and distress HIV-infected mothers experience during viral testing of their infants.

Mental Disorder in People Living with HIV/Aids in South Africa

We investigate the prevalence of mental disorder in people living with HIV/AIDS in a developing country context and examine the relationship between the presence of mental disorder and various independent variables. Nine-hundred HIV positive people were interviewed in 18 recruitment sites across five provinces in South Africa, using a cross-culturally validated diagnostic instrument and a structured socio-demographic and health information questionnaire. Prevalence of mental disorder was established using the Composite International Diagnostic Interview (CIDI). Chi-square, Fischer exact test, and binary logistic regression examined the relationship between mental health disorders and demographic characteristics, disease stage, CD4 count, and whether the person was on anti-retroviral treatment. A number of respondents (43.7%) were found to have a diagnosable mental disorder. Depression was the most common disorder (11.1% major and 29.9% mild depression), followed by alcohol abuse disorder (12.4%). The presence of mental disorder was significantly associated with gender, employment status, having children, and the clinical stage of the disease. Gender and the stage of disease were the best predictors of mental disorder. Rates of mental disorder were substantially higher in people living with HIV/AIDS than generally found in populations in developing countries and similar to HIV positive groupings in developed countries. Viral impacts on the brain, psychological reactions, and social conditions all contributed to the higher prevalence rates. Mental health interventions need to become a central part of comprehensive HIV/AIDS support, care, and treatment programmes.

HIV-infected mothers' foci of concern during the viral testing of their infants

The objective of this study was to explore HIV-infected mothers' most worrisome concerns during their infants' HIV viral testing. A total of 20 HIV-infected women consented to one antepartum and five postpartum study visits clustered around infant HIV viral testing time points. Content analysis was used to categorize maternal responses about their concerns. The majority (80%) of mothers identified infant health as the most worrisome concern during the prenatal and early postpartum periods. This concern declined after the second infant viral test result but rebounded before obtaining the final viral test. Once the final viral test result was known, the majority (60%) of mothers identified psychosocial issues as most worrisome. Maternal health did not surpass infant health or psychosocial issues as a primary concern. The primary concern of the HIV-infected mothers in this study was infant health during the infant viral testing period. Maternal health issues remained secondary to infant health and psychosocial issues as major concerns several months after infant viral testing was completed.

Difficulties reported by HIV-infected patients using antiretroviral therapy in Brazil

OBJECTIVE

To describe the degree of difficulty that HIV-infected patients have with therapy treatment.

INTRODUCTION

Patients perceptions about their treatment are a determinant factor for improved adherence and a better quality of life.

METHODS

Two cross-sectional analyses were conducted in public AIDS referral centers in Brazil among patients initiating treatment. Patients interviewed at baseline, after one month, and after seven months following the beginning of treatment were asked to classify and justify the degree of difficulty with treatment. Logistic regression was used for analysis.

RESULTS

Among 406 patients initiating treatment, 350 (86.2%) and 209 (51.5%) returned for their first and third visits, respectively. Treatment perceptions ranged from medium to very difficult for 51.4% and 37.3% on the first and third visits, respectively. The main difficulties reported were adverse reactions to the medication and scheduling. A separate logistic regression indicated that the HIV-seropositive status disclosure, symptoms of anxiety, absence of psychotherapy, higher CD4+ cell count (> 200/mm3) and high (> 4) adverse reaction count reported were independently associated with the degree of difficulty in the first visit, while CDC clinical category A, pill burden (> 7 pills), use of other medications, high (> 4) adverse reaction count reported and low understanding of medical orientation showed independent association for the third visit.

CONCLUSIONS

A significant level of difficulty was observed with treatment. Our analyses suggest the need for early assessment of difficulties with treatment, highlighting the importance of modifiable factors that may contribute to better adherence to the treatment protocol.

HIV-related stigma among people with HIV and their families: a qualitative analysis

We examined the interconnectedness of stigma experiences in families living with HIV, from the perspective of multiple family members. Semi-structured interviews were conducted with 33 families (33 parents with HIV, 27 children under age 18, 19 adult children, and 15 caregivers). Parents were drawn from the HIV Cost and Services Utilization Study, a representative sample of people in care for HIV in US. All of the families recounted experiences with stigma, including 100% of mothers, 88% of fathers, 52% of children, 79% of adult children, and 60% of caregivers. About 97% of families described discrimination fears, 79% of families experienced actual discrimination, and 10% of uninfected family members experienced stigma from association with the parent with HIV. Interpersonal discrimination seemed to stem from fears of contagion. Findings indicate a need for interventions to reduce HIV stigma in the general public and to help families cope with stigma.

Relationships among functional social support, HIV-related stigma, social problem solving, and depressive symptoms in people living with HIV: a pilot study

This cross-sectional exploratory study examined relationships among functional social support, HIV-related stigma, social problem solving, and depressive symptoms in a convenience sample of 30 men and nonpregnant women who sought care at two HIV outpatient clinics in the southeastern United States. Participants completed a set of self-report questionnaires at these clinics during scheduled regular visits. Data were analyzed using descriptive statistics. Consistent with other HIV studies, participants in this sample were at high risk for depression. Depressive symptoms were associated with more perceived HIV-related stigma, less social support provided by others, and dysfunctional social problem solving. These results are preliminary but important in identifying potential components for effective interventions to reduce the risk of depressive symptoms in persons with HIV.

HIV-positive mothers' disclosure of their serostatus to their young children: a review

One challenge faced by mothers living with HIV (MLWHs) is the decision about whether or not to disclose their HIV status to their young children, and how best to carry out the disclosure. Disclosure of their serostatus has emerged as one of the main concerns MLWHs have, and that decision can result in high levels of psychological distress. Concerns are exacerbated among MLWHs with younger children, due to the fact that they face additional worries, such as whether the child is old enough to understand, or will be able to keep the information confidential. A great deal of recent research--within approximately the past decade--has been conducted to investigate maternal disclosure of HIV, and the outcomes on children. This article reviews the current state of the research literature, focusing on factors that appear to influence whether or not mothers chose to disclose; characteristics of children who have been made aware of their mothers' serostatus relative to children who remain unaware; factors that appear to influence children's reactions to maternal disclosure; and implications of this research as well as future research directions.

An occupational therapy income-generation group for HIV-positive women in Uganda: Part 1

Little is known of the occupational therapy interventions available to occupational therapy clients living with the human immunodeficiency virus (HIV) in the developing world. This two-part series explores one group of female clients’ views of taking part in such an intervention; an occupational therapy income-generation group. In this, the first part of the article, the authors outline the relevant background literature, exploring research on support group attendance, social support for HIV-positive people and the value of income-generation activities for women in developing countries.

This material shows that people with chronic health conditions, especially those from potentially stigmatised groups, can obtain much-valued practical, psychological, social and economic support from therapeutic group attendance. This suggests that occupational therapy has much to offer this potential client group. The authors used this material to underpin a small qualitative study of ten HIV-positive Ugandan women taking part in an occupational therapy income-generation group. The methods used in this study, its findings and implications are detailed in part two of this article.