Gender and care: access to HIV testing, care, and treatment

Empowerment and utilization of HIV testing among partnered women in Zambia: Evidence from the Zambia demographic and health survey 2018

In Zambia, women are disproportionally more affected by HIV compared to men. This has mainly been attributed to harmful gender norms that enhance male dominance and disempower women, preventing them from exercising their right to negotiate for safe sex and utilizing HIV prevention services such as HIV testing. This study examined associations between empowerment and HIV testing among married and partnered women. We analyzed secondary data from the couple's recode of the 2018 Zambia demographic and health survey. Univariable and multivariable logistic regression analysis was conducted, and p<0.05 was considered statistically significant. We included a total of 5,328 married and partnered women in the analysis, of which 5057 (94.9%) had undergone an HIV test before. After adjusting for confounders, decision-making was the only independent predictor of HIV testing among measures of empowerment. Women who were highly empowered in decision-making were more likely to have undergone an HIV test compared to those who were less empowered (AOR = 2.1; 95% CI: 1.5, 2.9). Women aged 20-29 years (AOR = 2.4; 95% CI: 1.6, 3.6), 30-39 years (AOR = 5.3; 95% CI: 3.4, 8.2), or 40-49 years (AOR = 2.9; 95% CI: 1.9, 4.7), those with primary education (AOR = 2.4; 95% CI: 1.7, 3.4) or secondary and higher (AOR = 4.1; 95% CI: 2.3, 7.2), rich women (AOR = 2.4; 95% CI: 1.5, 3.7) or women with middle wealth (AOR = 1.5; 95% CI: 1.1, 2.2) and those who gave birth in the last 5 years (AOR = 3.3; 95% CI: 2.5, 4.5) were more likely to have been tested for HIV. This study highlights the critical influence of women's empowerment in decision-making on HIV testing. Additionally, level of education, wealth, age, and having given birth before are essential factors to consider in promoting HIV testing among women in Zambia.

Positive, Open, Proud: an adapted disclosure-based intervention to reduce HIV stigma

HIV stigma among people living with HIV (PLWH) is well documented and linked to adverse physical and mental health outcomes among this population. Further, stigma may affect HIV disclosure decisions, which has important individual and public health implications. For women, HIV stigma and disclosure may be compounded by gender-based discrimination and violence. Despite the ill effects of HIV stigma, particularly for women, few evidence-based disclosure interventions to reduce stigma among PLWH exist. However, there is strong evidence for the efficacy of Honest, Open, Proud (HOP), a disclosure-based stigma-reduction intervention for people with mental illness. Given that mental illness and HIV are similar in that they are both stigmatized yet concealable conditions, we propose using the ADAPT-ITT model to adapt HOP into Positive, Open, Proud, a disclosure-based stigma-reduction intervention for PLWH, describing its unique potential for women living with HIV.

Lifetime HIV testing among three samples of adults with histories of incarceration in Southern California

ABSTRACTJustice-impacted persons may inconsistently access HIV testing. This cross-sectional secondary analysis investigates lifetime HIV testing prevalence among adults with prior histories of incarceration in Southern California, United States, participating in health-focused programming (n = 3 studies). Self-reported demographic and lifetime HIV testing data were collected between 2017-2023; descriptive analyses were conducted. Across the three samples, at least 74% of participants were male; Latino and African American individuals accounted for nearly two-thirds of participants. Lifetime HIV testing ranged from 72.8% to 84.2%. Males were significantly more likely than females to report never being tested in two samples and accounted for >95% of those never tested. No statistically significant differences in testing were observed by race/ethnicity. Single young adults (ages 18-26) were less likely than their partnered peers to report testing. HIV testing is critical for ensuring that individuals access prevention and treatment. HIV testing among justice-impacted adults in this study was higher than in the general population, potentially due to opt-out testing in correctional settings. Nevertheless, these findings underscore the importance of implementing targeted interventions to reduce structural (e.g., health insurance, access to self-testing kits) and social barriers (e.g., HIV stigma) to increase HIV testing among justice-impacted males and single young adults.

Empowering people living with HIV (PLHIV): unveiling care gaps and identifying opportunities for improving care for PLHIV in Singapore and Hong Kong

INTRODUCTION

This study explored the behaviours of people living with HIV in Singapore and Hong Kong in terms of achieving and maintaining their physical and psychological wellbeing in relation to HIV, to identify the challenges and support needed in HIV care.

METHODS

This qualitative study involved 90-minute interviews among Singapore and Hong Kong people living with HIV aged ≥18 years to explore health-related quality of life perceptions and gaps in patient empowerment in HIV care during February-May 2022. The COM-B (C: Capability; O: Opportunity; M: Motivation; B: Behaviour) framework was used during data analysis to identify behaviour facilitators and barriers for people living with HIV to achieve and maintain their wellbeing. Detailed accounts of respondents' experience of living with and managing HIV, that is what worked well, unmet needs and perceived significance of wellbeing indicators, were analysed qualitatively via a combination of inductive content and deductive frameworks.

RESULTS

A total of 30 and 28 respondents were recruited from Singapore (SG) and Hong Kong (HK), respectively. Most respondents were aged 20-49 years (SG: 83.3%; HK: 64.3%), males (SG: 96.7%; HK: 92.9%), men who have sex with men (SG: 93.3%; HK: 71.4%), had university or higher education (SG: 73.3%; HK: 50.0%) and were fully employed (SG: 73.3%; HK: 57.1%). In both Singapore and Hong Kong, physical health was considered a key focus of overall wellbeing, albeit attention to long-term health associated with cardiovascular and renal health was less salient. The impact of symptoms, side effects of treatment, mood and sleep were among the top wellbeing indicators of importance. Respondents felt that insufficient information was provided by physicians, citing consultation time and resource constraints impeding further expression of concerns to their physicians during consultation. Respondents prioritized functional wellness and delegated psychosocial health to supportive care professionals, patient groups, families and/or friends.

CONCLUSIONS

There is a need in Singapore and Hong Kong to empower people living with HIV to establish better communications with their physicians and be more involved in their treatment journey and equally prioritize their psychosocial wellbeing.

Barriers to HIV testing and possible interventions to improve access to HIV healthcare among migrants, with a focus on migrant women: Results from a European survey

BACKGROUND

According to European Centre for Disease Prevention and Control (ECDC) reports, women and migrants are more likely to have delayed HIV diagnosis (CD4 <350 cells/mm3). As a follow-up to a previously published systematic review revealing a range of barriers to HIV testing among migrant women, the aim of the present study was to identify barriers to HIV testing from the perspective of service providers and to formulate possible interventions to improve access to HIV healthcare among migrants in Europe, with an emphasis on migrant women.

METHODS

Between November 2021 and February 2022 an online survey, consisting of 20 questions, was forwarded to 178 stakeholders and non-governmental organizations (NGOs) working with migrant populations in 33 countries from the World Health Organization (WHO) European region.

RESULTS

Forty-three responses from 14 countries were analysed. Most respondents (70%) judged migrants' access to healthcare as worse than that for the resident native population. Only 2/11 prevention interventions were available to all in at least 50% of participating countries. The three main barriers to accessing healthcare for migrant women and reasons for late HIV diagnosis among migrant women were stigma and discrimination, language barriers, and cultural barriers.

CONCLUSIONS

Many HIV prevention interventions are not free of charge for all within Europe. The results of this survey show that migrant women face many barriers to accessing healthcare and that these might contribute to late HIV diagnosis. Simplification of access to free healthcare for all, more awareness raising about HIV screening and prevention among migrant women, and more migrant-focused outreach programmes are suggested to improve migrant women's access to HIV healthcare in Europe.

Predictors and social determinants of HIV treatment engagement among post-partum Black women living with HIV in southeastern United States

AIM

Guided by Mcleroy's socio-ecological model, this study explored the predictors and social determinants of HIV treatment engagement among Black post-partum women living with HIV.

METHOD

Quantitative, research methodology.

DESIGN

We conducted a retrospective, secondary data analysis of 143 Black post-partum women living with HIV who received peripartum care in South-Florida, United States, from 2009 to 2017. We examined odds of immediate post-partum engagement at 3 months post-partum, and ongoing primary care engagement at 12 months post-partum.

RESULTS

The independent group analyses showed low levels of immediate post-partum (32.9%) and ongoing primary care engagement (24.5%). At the intrapersonal level, maternal prenatal health significantly affected both immediate post-partum and ongoing primary care engagement; and at the interpersonal level, HIV disclosure and intimate partner violence/abuse significantly affected immediate post-partum engagement. Also, immediate post-partum disengagement was a significant predictor for ongoing primary care disengagement.

CONCLUSION

This study provides timely and critical information to address recent calls for awareness and interventions to address issues on health disparities and inequities among racialized communities.

IMPACT

The study provides significant evidence on the effects of social determinants of health on health outcomes for Black women living with HIV. Critical understanding and assessment of these factors, together with proper, proactive interventions may help to gauge such negative effects. Healthcare providers taking care of Black women living with HIV ought to be cognizant of these factors, assess at-risk women and intervene accordingly to ensure that their care is not marginalized.

PATIENT/PUBLIC CONTRIBUTION

This study includes direct patient data from Black post-partum women living with HIV who were seen at prenatal and post-partum clinics wherein data for this study were obtained. The study results were presented locally, nationally and internationally to communities, organizations of healthcare providers, stakeholders and service-users, who further corroborated our findings, and provided insights and future recommendations.

Muslim women's perspectives on the barriers to sexually transmitted infections testing and diagnosis in Saudi Arabia

Background

Muslim women are especially vulnerable to sexually transmitted infections (STI) and are at higher risk of under-detection. Evidence on the unique barriers to STI testing and diagnosis among Muslim communities is severely lacking. Understanding the complexity of accessing STI testing and diagnosis in Muslim communities is an area that requires further exploration. We aimed to explore the multilevel barriers to STI testing and diagnosis among Muslim women.

Methods

We conducted qualitative semi-structured interviews informed by the ecological model of health. This study took place in Riyadh Saudi Arabia in 2019 with women aged over 18. Data were analysed using reflexive thematic analysis.

Results

Twenty-eight women were interviewed from different ages, marital status, employment, and educational levels. Muslim women's perceived barriers to STI testing and diagnosis included personal, socio-cultural, and service-level barriers. Lack of knowledge about STIs, denial, and underestimating the seriousness of infection and symptoms were among the many individual barriers to STIs testing and diagnosis. Religious views towards extramarital sex and negative views of people with STIs is a significant barrier to STI testing and diagnosis. Lack of patient confidentiality and providers' judgement and mistreatment were also cited as barriers to seeking healthcare.

Conclusion

Barriers to STI testing and diagnosis exist on many levels including personal, socio-cultural, religious, and healthcare services, and at policy level. Multilevel interventions are needed to reduce the stigma of STIs and facilitate access to sexual health services among Muslims. It is our recommendation that policy and research efforts are directed to enhance trust in the doctor-patient relationship through better clinical training as well as implementing stricter regulations to protect patients' confidentiality in healthcare settings.

Muslim women's knowledge, views, and attitudes towards sexually transmitted infections in Saudi Arabia: A qualitative study

BACKGROUND

The cultural sensitivity surrounding sexuality in Islamic communities has an impact on awareness and prevention of sexually transmitted infections (STIs). This study explores Muslim women's knowledge, views, and attitudes towards STIs and people living with HIV/AIDs in Saudi Arabia.

METHODS

We conducted qualitative semi-structured interviews with Muslim women from Saudi Arabia. Interviews took place in a public hospital in Riyadh, Saudi Arabia in 2019. Data were transcribed, coded, and analysed using a reflexive thematic analysis.

RESULTS

Twenty-eight women were interviewed, the majority were college educated and employed. Participants lacked knowledge about STIs, and there were significant misconceptions. The majority of women expressed extremely negative attitudes towards STIs, particularly towards people living with HIV/AIDS. Participants believed that judgemental attitudes and stigmatisation of people with HIV/AIDS were justified if an infection was transmitted through extramarital sex. Men were believed to be the source of STIs, and STIs were viewed as punishment from God for extramarital sexual relations that are forbidden in Islam. Protection against STIs was believed to be achieved by strengthening religious beliefs.

CONCLUSION

Attitudes towards people with STIs, HIV/AIDS in particular, were highly influenced by religious views towards extramarital sex, as well as lack of knowledge and misconceptions. There is an urgent need for accurate information and improved awareness of sexual health including STIs among Muslims in Saudi Arabia. Public health efforts should be directed towards reducing stigma and discrimination against people living with HIV/AIDS in Saudi Arabia and other Islamic communities.

Gearing up for PrEP in the Middle East and North Africa: An Initial Look at Willingness to Take PrEP among Young Men Who Have Sex with Men in Beirut, Lebanon

The Middle East and North Africa (MENA) is one of only two global regions where rates of HIV are currently on the rise. In Lebanon, new HIV infections are increasing most rapidly among young men who have sex with men (YMSM). While, the majority of YMSM in Lebanon report having recently engaged in condomless anal intercourse, many report reluctance to seek HIV prevention services for fear of stigma and discrimination. Pre-exposure prophylaxis (PrEP) is an effective alternative HIV prevention strategy but there is a dearth of research looking at willingness to take PrEP among YMSM in MENA. This study is the first to delineate factors associated with willingness to take PrEP among a cohort of 218 YMSM recruited from Beirut, Lebanon. Over half (55.5%) reported willingness to take PrEP. At the bivariate level, knowledge of HIV risk, awareness of PrEP, being in a relationship, greater judgementalism about sex in communication with peers, greater number of types of gay-related discrimination experienced, sense of community among YMSM, having had recent condomless anal sex with positive or unknown status partner, and the use of substances just prior to or during sex were each associated with greater willingness to take PrEP. When entered into a linear regression analysis, use of substances just prior to or during sex and sense of community among YMSM remained significant predictors of PrEP willingness. Intervention efforts focused on increasing PrEP uptake among YMSM in MENA should consider the influence substance use and social factors on willingness to take PrEP.

Access to maternal-child health and HIV services for women in North-Central Nigeria: A qualitative exploration of the male partner perspective

BACKGROUND

In much of sub-Saharan Africa, male partners play influential roles in women's access to maternal-child healthcare, including prevention of mother-to-child transmission of HIV services. We explored male partner perspectives on women's access to maternal-child healthcare in North-Central Nigeria.

METHODS

Three focus groups were conducted with 30 men, purposefully-selected on the basis of being married, and rural or urban residence. Major themes explored were men's maternal-child health knowledge, gender power dynamics in women's access to healthcare, and peer support for pregnant and postpartum women. Data were manually analyzed using Grounded Theory, which involves constructing theories out of data collected, rather than applying pre-formed theories.

RESULTS

Mean participant age was 48.3 years, with 36.7% aged <40 years, 46.7% between 41 and 60 years, and 16.6% over 60 years old. Religious affiliation was self-reported; 60% of participants were Muslim and 40% were Christian. There was consensus on the acceptability of maternal-child health services and their importance for optimal maternal-infant outcomes. Citing underlying patriarchal norms, participants acknowledged that men had more influence in family health decision-making than women. However, positive interpersonal couple relationships were thought to facilitate equitable decision-making among couples. Financial constraints, male-unfriendly clinics and poor healthcare worker attitudes were major barriers to women's access and male partner involvement. The provision of psychosocial and maternal peer support from trained women was deemed highly acceptable for both HIV-positive and HIV-negative women.

CONCLUSIONS

Strategic engagement of community leaders, including traditional and religious leaders, is needed to address harmful norms and practices underlying gender inequity in health decision-making. Gender mainstreaming, where the needs and concerns of both men and women are considered, should be applied in maternal-child healthcare education and delivery. Clinic fee reductions or elimination can facilitate service access. Finally, professional organizations can do more to reinforce respectful maternity care among healthcare workers.

Women's healthcare decision-making capacity and HIV testing in sub-Saharan Africa: a multi-country analysis of demographic and health surveys

BACKGROUND

Global commitment to stop Human Immunodeficiency Virus (HIV) and ensure access to HIV treatment calls for women empowerment, as these efforts play major roles in mother-to-child transmission. We examined the association between women's healthcare decision-making capacity and uptake of HIV testing in sub-Saharan Africa.

METHODS

We used data from the current Demographic and Health Surveys (DHS) of 28 countries in sub-Saharan Africa, conducted between January 1, 2010 and December 31, 2018. At the descriptive level, we calculated the prevalence of HIV testing in each of the countries. This was followed by the distribution of HIV testing across the socio-demographic characteristics of women. Finally, we used binary logistic regression assess the likelihood of HIV testing uptake by women's health care decision-making capacity and socio-demographic characteristics. The results were presented as Crude Odds Ratios (COR) and Adjusted Odds Ratios (AOR) with their corresponding 95% confidence intervals signifying precision. Statistical significance was set at p-value < 0.05.

RESULTS

We found that prevalence of HIV testing uptake in the 28 sub-Saharan African countries was 64.4%, with Congo DR having the least (20.2%) and the highest occurred in Rwanda (97.4%). Women who took healthcare decisions alone [COR = 3.183, CI = 2.880-3.519] or with their partners [COR = 2.577, CI = 2.335-2.844] were more likely to test for HIV, compared to those whose healthcare decisions were taken by others, and this persisted after controlling for significant covariates: [AOR = 1.507, CI = 1.321-1.720] and [AOR = 1.518, CI = 1.334-1.728] respectively.

CONCLUSION

Sub-Saharan African countries intending to improve HIV testing need to incorporate women's healthcare decision-making capacity strategies. These strategies can include education and counselling. This is essential because our study indicates that the capacity of women to make healthcare decisions has an association with decision to test for their HIV status.

The rapid CD4 + T-lymphocyte decline and human immunodeficiency virus progression in females compared to males

CD4 + T-lymphocyte counts are used to assess CD4 + decline and the stage of human immunodeficiency virus (HIV) progression in HIV-infected patients. Clinical observation suggests that HIV progress more rapid in females than males. Of the original 5000 HIV-infected population of Western New York HIV/AIDS, Referral Center at Erie County Medical Center (ECMC), 1422 participated in the cohort study. We identified 333 HIV-infected patients with CD4 + T-cell-counts ≥ 500/µƖ, among them 178 met the inclusion criteria for the 10-year study. Females had higher mode (600 vs. 540) and mean (741.9 vs. 712.2) CD4 + counts than males at baseline. However, CD4 + declined faster among females in a shorter time than males (234.5 vs. 158.6, P < 0.004), with rapid HIV progression. Univariate analyses determined that females had a 40% higher risk for CD4 + decline than males. The bivariate analyses specified CD4 + decline remained greater in females than males. Multivariate analyses which employed Cox’s proportional Hazard-Model to adjust for numerous variables simultaneously identified women had almost twice the risk for CD4 + decline and rapid HIV progression than males (RR = 1.93; 95%CI 1.24, 2.99). Although the biological mechanism remains unknown, findings suggest gender differences in CD4 + decline, with a higher risk of rapid HIV progression and shorter longevity in females.

HIV in Lebanon: Reasons for Testing, Engagement in Care, and Outcomes in Patients with Newly Diagnosed HIV Infections

Little is known about clinical presentation and cascade of care among patients living with HIV (PLWH) in Beirut, Lebanon. The study aims to examine the reasons for HIV testing and to evaluate the clinical characteristics of, predictors of advanced HIV stage at presentation in, and rates of ART initiation, retention in care, and viral load suppression among PLWH in Lebanon. We conducted a retrospective study of PLWH presenting to a tertiary-care centre-affiliated outpatient clinic from 2008 to 2016 with new HIV infection diagnoses. We identified a total of 423 patients: 89% were men, 55% were 30-50 years old, and 58% self-identified as men who have sex with men. About 35% of the patients had concurrent sexually transmitted diseases at the time of HIV diagnosis. Thirty percent of infection cases were identified by provider-initiated HIV testing, 36% of cases were identified by patient-initiated testing, and 34% of patients underwent testing for screening purposes. The proportion of individuals presenting with advanced HIV disease decreased from 40% in 2008-2009 to 24% in 2014-2015. Age older than 50 years and identification of HIV by a medical provider were independent predictors of advanced HIV infection at presentation. Among patients having indications for treatment (n = 253), 239 (94%) were prescribed antiretroviral therapy, and 147 (58%) had evidence of viral suppression at 1 year. Furthermore, 266 patients (63%) were retained in care. The care continuum for PLWH in Lebanon is comparable with those in high-income countries yet still far behind the Joint United Nations Programme on HIV/AIDS 90-90-90 set target.

Barriers to HIV testing uptake among men in sub-Saharan Africa: a scoping review

Introduction: HIV testing among men remains low globally and in sub-Saharan Africa (SSA) in particular, when compared with their female counterparts. The aim of this study was to synthesise evidence on barriers to HIV testing among men in SSA using a scoping review method.Methods: A scoping review was conducted, guided by Arksey and O'Malley's framework. A search was made in PubMed, American Doctoral Dissertations via EBSCOhost, Union Catalogue of Theses and Dissertations and SA ePublications via SABINET Online and World Cat Dissertations, Theses via OCLC and Google Scholar. The PRISMA (preferred reporting items for systematic reviews and meta-analyses) chart was used to document the review process. The PRISMA extension for scoping reviews - PRISMA-ScR: checklist and explanation - was also used. The mixed method appraisal tool version 2018 was used to determine the methodological quality of the included studies. Thematic analyses were conducted using NVivo version 11.Results: Key barriers to HIV testing among men in SSA were knowledge of HIV, fear of testing positive for HIV, stigma associated with HIV, healthcare providers' services, confidentiality, and clinic setting.Conclusion: Structural and individual factors present barriers to HIV testing uptake among men in SSA. Community and home-based initiatives have the potential to improve the uptake of HIV testing among men in SSA, considering the confidentiality concerns posed by clinic settings.

Gender, HIV-Related Stigma, and Health-Related Quality of Life Among Adults Enrolling in HIV Care in Tanzania

HIV-related stigma has been associated with worse health-related quality of life (HRQoL) among people living with HIV (PLWH). Little is known about how different types of HIV-related stigma (i.e., anticipatory, internalized, or enacted HIV-related stigma) influence HRQoL and whether these relationships differ by gender. The sample included 912 PLWH aged 18 years or older enrolling in HIV care at four health facilities in Tanzania. HRQoL was assessed with the life satisfaction and overall function subscales of the HIV/AIDS-Targeted Quality of Life (HAT-QoL) instrument. Sex-stratified multivariable logistic regression modeled the association of anticipatory, internalized, and enacted HIV-related stigma on poor HRQoL. Across all participants, the mean life satisfaction score was 63.4 (IQR: 43.8, 81.3) and the mean overall function score was 72.0 (IQR: 58.3, 91.7). Mean HRQoL scores were significantly higher for women compared to men for overall function (5.1 points higher) and life satisfaction (4.3 points higher). Fourteen percent of respondents reported recent enacted HIV-related stigma and 13% reported recent medium or high levels of internalized stigma. In multivariable models, high internalized and high anticipatory stigma were significantly associated with higher odds of poor life satisfaction and poor overall function in both men and women. Psychosocial interventions to prevent or reduce the impact of internalized and anticipatory stigma may improve HRQoL among persons in HIV care. Future research should longitudinally examine mechanisms between HIV-related stigma, poor HRQoL, and HIV care outcomes.

Factors affecting HIV counselling and testing among Ethiopian women aged 15-49

BACKGROUND

HIV voluntary counseling and testing (VCT) is a crucial gateway to all strategies related to care, prevention and treatment of human immunodeficiency virus (HIV) infection. Nevertheless, utilization of voluntary counselling and testing (VCT) service among adults is very low in Ethiopia. The objective of this study is to identify determinants associated with VCT utilization among adult women aged 15-49 in Ethiopia.

METHODS

A cross-sectional study was conducted based on data taken from the Ethiopian Demographic Health Survey (EDHS) 2016. Using cluster sampling, 14,369 women aged 15-49 years were selected from all the nine administrative regions and two city administrations. Logistic regression was used to analyze factors associated with HIV VCT utilization.

RESULTS

Overall prevalence of ever tested for HIV was 53% (95% CI, 52, 54). Aged 20-44, ever married, being at higher socio economic position (SEP) and having risky sexual behavior were factors which are positively associated with VCT utilization. Being Muslims in urban and protestants in rural were factors significantly and negatively associated with VCT utilization. Those who had stigmatizing attitude both in urban and rural and who had comprehensive knowledge in rural were less likely to utilize VCT service.

CONCLUSION

VCT utilization among women in Ethiopia is demonstrating better improvement in recent years. However, stigmatizing attitude continued to be among the major factors, which are negatively affecting VCT uptake among women in Ethiopia. Concerted efforts should be made by all stakeholders to mitigate stigma, improve socio economic inequities and increase awareness on the benefit of VCT in controlling HIV in the society. In this aspect, the role of religious leader, schools, health extension workers and community leaders should not be undermined.

A bootstrapping approach for generating an inverse distance weight matrix when multiple observations have an identical location in large health surveys

Spatial weight matrices play a key role in econometrics to capture spatial effects. However, these constructs are prone to clustering and can be challenging to analyse in common statistical packages such as STATA. Multiple observations of survey participants in the same location (or cluster) have traditionally not been dealt with appropriately by statistical packages. It is common that participants are assigned Geographic Information System (GIS) data at a regional or district level rather than at a small area level. For example, the Demographic Health Survey (DHS) generates GIS data at a cluster level, such as a regional or district level, rather than providing coordinates for each participant. Moreover, current statistical packages are not suitable for estimating large matrices such as 20,000 × 20,000 (reflective of data within large health surveys) since the statistical package limits the N to a smaller number. In addition, in many cases, GIS information is offered at an aggregated level of geographical areas. To alleviate this problem, this paper proposes a bootstrap approach that generates an inverse distance spatial weight matrix for application in econometric analyses of health survey data. The new approach is illustrated using DHS data on uptake of HIV testing in low and middle income countries.

Mapping evidence of intervention strategies to improving men's uptake to HIV testing services in sub-Saharan Africa: A systematic scoping review

BACKGROUND

HIV testing serves as a critical gateway for linkage and retention to care services, particularly in sub-Saharan African countries with high burden of HIV infections. However, the current progress towards addressing the first cascade of the 90-90-90 programme is largely contributed by women. This study aimed to map evidence on the intervention strategies to improve HIV uptake among men in sub-Saharan Africa.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's (2005) framework and Levac et al. (2010) recommendation for methodological enhancement for scoping review studies. We searched for eligible articles from electronic databases such as PubMed/MEDLINE; American Doctoral Dissertations via EBSCO host; Union Catalogue of Theses and Dissertations (UCTD); SA ePublications via SABINET Online; World Cat Dissertations; Theses via OCLC; and Google Scholar. We included studies from January 1990 to August 2018. We used the PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. The Mixed Method Appraisal Tool version 2018 was used to determine the methodological quality of the included studies. We further used NVivo version 11 to aid with content thematic analysis.

RESULTS

This study revealed that teaching men about HIV; Community-Based HIV testing; Home-Based HIV testing; Antenatal Care HIV testing; HIV testing incentives and HIV Self-testing are important strategies to improving HIV testing among men in sub-Saharan Africa. The need for improving programmes aimed at giving more information to men about HIV that are specifically tailored for men, especially given their poor uptake of HIV testing services was also found. This study further revealed the need for implementing Universal Test and Treat among HIV positive men found through community-based testing strategies, while suggesting the importance of restructuring home-based HIV testing visits to address the gap posed by mobile populations.

CONCLUSION

The community HIV testing, as well as, HIV self-testing strategies showed great potential to increase HIV uptake among men in sub-Saharan Africa. However, to address poor linkage to care, ART should be initiated soon after HIV diagnosis is concluded during community testing services. We also recommend more research aimed at addressing the quality of HIV self-testing kits, as well as, improving the monitoring systems of the distributed HIV self-testing kits.

Timing and Predictors of Initiation on Antiretroviral Therapy Among Newly-Diagnosed HIV-Infected Persons in South Africa

Despite a decade of advancing HIV/AIDS treatment policy in South Africa, 20% of people living with HIV (PLHIV) eligible for antiretroviral treatment (ART) remain untreated. To inform universal test and treat (UTT) implementation in South Africa, this analysis describes the rate, timeliness and determinants of ART initiation among newly diagnosed PLHIV. This analysis used routine data from 35 purposively selected primary clinics in three high HIV-burden districts of South Africa from June 1, 2014 to March 31, 2015. Kaplan-Meier survival curves estimated the rate of ART initiation. We identified predictors of ART initiation rate and timely initiation (within 14 days of eligibility determination) using Cox proportional hazards and multivariable logistic regression models in Stata 14.1. Based on national guidelines, 6826 patients were eligible for ART initiation. Under half of men and non-pregnant women were initiated on ART within 14 days (men: 39.7.0%, 95% CI 37.7-41.9; women: 39.9%, 95% CI 38.1-41.7). Pregnant women initiated at a faster rate (within 14 days: 87.6%, 86.1-89.0). ART initiation and timeliness varied significantly by district, facility location, and age, with little to no variation by World Health Organization stage, or CD4 count. Men and non-pregnant women newly diagnosed with HIV who are eligible for ART in South Africa show suboptimal timeliness of ART initiation. If treatment initiation performance is not improved, UTT implementation will be challenging among men and non-pregnant women. UTT programming should be tailored to district and location categories to address contextual differences influencing treatment initiation.

Actual Versus Perceived HIV Testing Norms, and Personal HIV Testing Uptake: A Cross-Sectional, Population-Based Study in Rural Uganda

HIV testing is an essential part of treatment and prevention. Using population-based data from 1664 adults across eight villages in rural Uganda, we assessed individuals' perception of the norm for HIV testing uptake in their village and compared it to the actual uptake norm. In addition, we examined how perception of the norm was associated with personal testing while adjusting for other factors. Although the majority of people had been tested for HIV across all villages, slightly more than half of men and women erroneously thought that the majority in their village had never been tested. They underestimated the prevalence of HIV testing uptake by 42 percentage points (s.d. = 17 percentage points), on average. Among men, perceiving that HIV testing was not normative was associated with never testing for HIV (AOR = 2.6; 95% CI 1.7-4.0, p < 0.001). Results suggest an opportunity for interventions to emphasize the commonness of HIV testing uptake.

Linkage between HIV diagnosis and care: Understanding the role of gender in a Northern Province in Vietnam

Early linkage to HIV care is associated significantly with improved patient outcomes and reduced the risk of HIV transmission. However, delays between HIV diagnosis and registering for care have prevailed in Vietnam. The aim of researchers in this study is to examine linkages to care for individuals newly diagnosed with HIV in 2014, especially to highlight the impact of gender upon these linkages in a Northern Province of Ninh Binh. We collected secondary data of all 125 eligible HIV positive people diagnosed in 2014 and conducted a gender-based descriptive analysis of their registration to care within 6 months. Nineteen in-depth interviews and two focus group discussions were completed. We found that women accounted for one-third of newly diagnosed cases (42/125), but initiated HIV treatment at an earlier stage of HIV disease than men (65% women at stage 1, 2 versus 31% in men). Stigma and discrimination was greater among women while inadequate awareness of treatment was greater for men. Dissatisfaction with HIV testing and counseling and no or passive referral to treatment were other barriers for both the genders for enrolling in care services after diagnosis.

A qualitative analysis of multi-level barriers to HIV testing among women in Lebanon

While the number of HIV cases in the Middle East and North Africa region is low compared to other regions, recent studies show that incidence is increasing especially among high-risk populations; in particular, little is known about women and HIV in the region. Through semi-structured interviews with sexual healthcare providers and staff at non-governmental organisations, we sought to understand barriers to HIV testing among women in Lebanon. Using snowball sampling, key informants were recruited from greater Beirut (12 physicians, 9 non-governmental organisation staff). Data were analysed using a grounded theory framework. Findings identified barriers to HIV testing among women at each level of an adapted social-ecological model (i.e. social-cultural barriers, policy barriers, interpersonal healthcare provider barriers and intrapersonal barriers). Primary findings include the culture of sex as taboo; lack of sexual health education among women; fear of disclosing HIV testing and diagnosis; financial barriers linked to stigmatising insurance policies; and provider attitudes towards women. Findings can be used to inform HIV-related sexual health interventions at multiple levels for women in Lebanon and the greater region.

Female healthcare professionals' behaviour and attitudes in the context of the feminisation of HIV/AIDS: gender vulnerability analysis

In only a few years, HIV/AIDS became a severe public health problem worldwide. More recently, the phenomenon of feminisation has substantially modified the epidemiological profile of the pandemic. Drawing on Grounded Theory, this qualitative, descriptive study examines the adoption of HIV/AIDS prevention measures and practices by women health professionals. Data were acquired by semi-structured interviews of 12 women working as health professionals providing care for HIV-seropositive women. Analysis of the results showed how, as women, the participants felt safe and protected against HIV in a so-called stable relationship, because they relied on factors such as trust in their companion, and perceived themselves as vulnerable and exposed to the risk of sexual contamination. As health professionals, they revealed concerns relating to care for women with HIV, ranging from speculations about how the women were contaminated, to the sensitivity, as women professionals, to put themselves in the place of the women with HIV and, also as professionals, expressed fear of contamination through accidents with biological material. It was concluded that, despite understanding the importance of adopting self-protective HIV-prevention measures and practices, they admitted the existence of vulnerability from occupational rather than sexual risk, and accordingly deployed protective measures against workplace accidents, but failed to use condoms and thus continued to be exposed to HIV in their sexual relations.

Evaluating Religious Influences on the Utilization of Maternal Health Services among Muslim and Christian Women in North-Central Nigeria

Introduction. Uptake of antenatal services is low in Nigeria; however, indicators in the Christian-dominated South have been better than in the Muslim-dominated North. This study evaluated religious influences on utilization of general and HIV-related maternal health services among women in rural and periurban North-Central Nigeria. Materials and Methods. Targeted participants were HIV-positive, pregnant, or of reproductive age in the Federal Capital Territory and Nasarawa. Themes explored were utilization of facility-based services, provider gender preferences, and Mentor Mother acceptability. Thematic and content approaches were applied to manual data analysis. Results. Sixty-eight (68) women were recruited, 72% Christian and 28% Muslim. There were no significant religious influences identified among barriers to maternal service uptake. All participants stated preference for facility-based services. Uptake limitations were mainly distance from clinic and socioeconomic dependence on male partners rather than religious restrictions. Neither Muslim nor Christian women had provider gender preferences; competence and positive attitude were more important. All women found Mentor Mothers highly acceptable. Conclusion. Barriers to uptake of maternal health services appear to be minimally influenced by religion. ANC/PMTCT uptake interventions should target male partner buy-in and support, healthcare provider training to improve attitudes, and Mentor Mother program strengthening and impact assessment.

Living Day by Day: The Meaning of Living With HIV/AIDS Among Women in Lebanon

We examined the meaning of living with HIV/AIDS among women in Lebanon. Ten women living with HIV/AIDS (WLWHA) described their experiences via semistructured in-depth interviews. They navigated a process of HIV diagnosis acceptance that incorporated six overlapping elements: receiving the news, accessing care, starting treatment, navigating disclosure decisions, negotiating stigma, and maintaining stability. Through these elements, we provide a framework for understanding three major themes that were constructed during data analysis: Stand by my side: Decisions of disclosure; Being "sick" and feeling "normal": Interacting with self, others, and society; and Living day by day: focusing on the present. We contribute to the existing literature by providing a theoretical framework for understanding the process of diagnosis and sero-status acceptance among WLWHA. This was the first study of its kind to examine the meaning of living with HIV/AIDS among women in a Middle Eastern country.

Seven year review of retention in HIV care and treatment in federal medical centre Ido-Ekiti

INTRODUCTION

Poor retention of patients in care is a major driver of poor performance and increased morbidity and mortality in HIV/AIDS programme despite the expansion and advancement Anti-retroviral Therapy (ART). The objective of this study is to assess retention rates and possible determining factors in People Living with HIV (PLHIV) on ART.

METHODS

This is a descriptive, cross-sectional study conducted in Federal Medical Center, Ido-Ekiti, Nigeria. Medical records of clients who were enrolled in ART Care and support unit (HIV Clinic) of the health facility from 2005 to 2012 were reviewed and analyzed using SPSS version 16. A total of 621 client records were reviewed for basic demographic information, CD4 count, WHO stage, number of follow-up visit, client ART status and client retention status (defined as client attending at least one clinic visit in 2012.

RESULTS

A total of 347(63%) patients were retained in care and 208(37%) were not retained over the seven year review period. Retention was statistically significant with age (P-value 0.031), ART status (P-value 0.000) baseline CD4 (P-value 0.004), year of diagnosis and ART initiation (P-value= 0.027). Poor retention was associated decreasing age, pre-ART client, HIV stage 1&IV client and baseline CD4 above 400cell/mm(3).

CONCLUSION

Retention in care of PLHIV is a minimum necessary condition for maintaining or restoring health in the long run. The strategies to sustain and improve retention rate should be adopted to maximize ART benefits. A follow-up study on other factors affecting retention from diagnosis to long term retention ART programme is recommended.

Interventions to improve or facilitate linkage to or retention in pre-ART (HIV) care and initiation of ART in low- and middle-income settings--a systematic review

INTRODUCTION

Several approaches have been taken to reduce pre-antiretroviral therapy (ART) losses between HIV testing and ART initiation in low- and middle-income countries, but a systematic assessment of the evidence has not yet been undertaken. The aim of this systematic review is to assess the potential for interventions to improve or facilitate linkage to or retention in pre-ART care and initiation of ART in low- and middle-income settings.

METHODS

An electronic search was conducted on Medline, Embase, Global Health, Web of Science and conference databases to identify studies describing interventions aimed at improving linkage to or retention in pre-ART care or initiation of ART. Additional searches were conducted to identify on-going trials on this topic, and experts in the field were contacted. An assessment of the risk of bias was conducted. Interventions were categorized according to key domains in the existing literature.

RESULTS

A total of 11,129 potentially relevant citations were identified, of which 24 were eligible for inclusion, with the majority (n=21) from sub-Saharan Africa. In addition, 15 on-going trials were identified. The most common interventions described under key domains included: health system interventions (i.e. integration in the setting of antenatal care); patient convenience and accessibility (i.e. point-of-care CD4 count (POC) testing with immediate results, home-based ART initiation); behaviour interventions and peer support (i.e. improved communication, patient referral and education) and incentives (i.e. food support). Several interventions showed favourable outcomes: integration of care and peer supporters increased enrolment into HIV care, medical incentives increased pre-ART retention, POC CD4 testing and food incentives increased completion of ART eligibility screening and ART initiation. Most studies focused on the general adult patient population or pregnant women. The majority of published studies were observational cohort studies, subject to an unclear risk of bias.

CONCLUSIONS

Findings suggest that streamlining services to minimize patient visits, providing adequate medical and peer support, and providing incentives may decrease attrition, but the quality of the current evidence base is low. Few studies have investigated combined interventions, or assessed the impact of interventions across the HIV cascade. RESULTS from on-going trials investigating POC CD4 count testing, patient navigation, rapid ART initiation and mobile phone technology may fill the quality of evidence gap. Further high-quality studies on key population groups are required, with interventions informed by previously reported barriers to care.

Reproductive Tract Infections in Rural Vietnam, Women's Knowledge, and Health-Seeking Behavior: A Cross-Sectional Study

We interviewed 1,805 women in a rural setting in Vietnam with the aim of investigating women's knowledge regarding reproductive tract infections (RTIs) and their health-seeking behavior. We found that women's overall knowledge was poor. Furthermore, only one-third of the symptomatic women sought health care. RTIs affect millions of women globally each year. Most vulnerable are women in low- and middle-income countries where poverty and gender inequities affect their access to health care services. Findings from our study can be used in similar rural settings worldwide to understand and manage the widespread problem of RTIs.

Clinical and epidemiological features of HIV/AIDS infection among migrants at first access to healthcare services as compared to Italian patients in Italy: a retrospective multicentre study, 2000-2010

PURPOSE

Migrants account for approximately 8.7% of the resident population in Italy. The immigration status deeply influences access to prevention and care, thus contributing to increase the burden of HIV/AIDS among such a fragile category. The aim of this study was to investigate socio-demographic and baseline clinical and immunological features of HIV-infected migrants, as compared to Italians.

METHODS

We retrospectively analysed data for all the 1,611 HIV-infected migrant patients and a random sample of 4,230 HIV-infected Italian patients aged 18 or older who first accessed nine Italian clinical centres in 2000-2010 and were followed up at least 1 year. Differences in baseline characteristics between migrants and Italians were evaluated in univariate analysis, while factors associated with late presentation were evaluated in multivariate analysis using logistic regression models.

RESULTS

The baseline profile differs between the HIV-infected migrant and Italian patients, substantially reflecting what reported by current statistics in terms of gender, age, risk category as well as clinical features. Late presenters were more frequent among migrants as compared to Italians (53.0 vs 45.8%; adjusted odds ratio [(AOR) = 1.55, 95% confidence interval (CI) 1.34-1.78]. Other factors associated with late presentation included increasing age, as well as undocumented legal status among foreign-born subjects (AOR = 1.41, 95% CI 0.97-2.04), though of borderline significance.

CONCLUSIONS

Late presentation still represents a relevant problem despite the advances in the management of HIV infection. More efforts are needed to allow early diagnosis and access to care among the most vulnerable, such as undocumented foreign-born subjects in a country where migration flows are on the rise.

Determinants of HIV testing among Nigerian couples: a multilevel modelling approach

In this article we analyse the determinants of HIV testing among Nigerian couples using Demographic and Health Survey data set (2008). This study is motivated by the fact that although there is a strong willingness from the Nigerian Government to examine new HIV preventions approaches such as Pre-Exposure Prophylaxis for HIV (PrEP) and Treatment as Prevention (TasP) for HIV serodiscordant couples, the implementation of such policies would require the HIV status of each partner in the couple to be known. This is far to be achieved in the Nigerian context since in Nigeria only 6% of couples know their HIV status. In order to identify potential policies that are needed to increase HIV testing uptake, we use a three-level random intercept logistic model to separately explore the determinants of knowing HIV status among female and male partners. The use of the multilevel modelling allows including the unobserved heterogeneity at the village and state level that may affect HIV testing behaviours. Our results indicate that education, wealth, stigma, HIV knowledge and perceived risk are predictors of HIV testing among both partners while routine provider initiated testing appears to be very effective to increase HIV testing among women. The introduction of financial incentives as well as an increase in routine testing and home-based testing may be needed for large scale increase in HIV testing prior to the implementation of new HIV prevention technologies among discordant couples.

Coming home to die? The association between migration and mortality in rural Tanzania before and after ART scale-up

Background

Prior to the scale-up of antiretroviral therapy (ART), demographic surveillance cohort studies showed higher mortality among migrants than residents in many rural areas.

Objectives

This study quantifies the overall and AIDS-specific mortality between migrants and residents prior to ART, during ART scale-up, and after widespread availability of ART in Rufiji district in Tanzania.

Design

In Health and Demographic Surveillance System (HDSS), the follow-up of individuals aged 15–59 years was categorized into three periods: before ART (1998–2003), during ART scale-up (2004–2007), and after widespread availability of ART (2008–2011). Residents were those who never migrated within and beyond HDSS, internal migrants were those who moved within the HDSS, and external migrants were those who moved into the HDSS from outside. Mortality rates were estimated from deaths and person-years of observations calculated in each time period. Hazard ratios were estimated to compare mortality between migrants and residents. AIDS deaths were identified from verbal autopsy, and the odds ratio of dying from AIDS between migrants and residents was estimated using the multivariate logistic regression model.

Results

Internal and external migrants experienced higher overall mortality than residents before the introduction of ART. After widespread availability of ART overall mortality were similar for internal and external migrants. These overall mortality experiences observed were similar for males and females. In the multivariate logistic regression model, adjusting for age, sex, education, and social economic status, internal migrants had similar likelihood of dying from AIDS as residents (adjusted odds ratio [AOR]=1.14, 95% confidence interval [CI]: 0.70–1.87) while external migrants were 70% more likely to die from AIDS compared to residents prior to the introduction of ART (AOR=1.70, 95% CI: 1.06–2.73). After widespread availability of ART with the same adjustment factors, the odds of dying from AIDS were similar for internal migrants and residents (AOR=1.56, 95% CI: 0.80–3.04) and external migrants and residents (AOR=1.42, 95% CI: 0.76–2.66).

Conclusions

Availability of ART has reduced the number of HIV-infected migrants who would otherwise return home to die. This has reduced the burden on rural communities who had cared for the return external migrants.

HIV prevalence and demographic determinants of unprotected anal sex and HIV testing among men who have sex with men in Beirut, Lebanon

The limited epidemiological data in Lebanon suggest that HIV incident cases are predominantly among men who have sex with men (MSM). We assessed the prevalence of HIV and demographic correlates of condom use and HIV testing among MSM in Beirut. Respondent-driven sampling was used to recruit 213 participants for completion of a behavioral survey and an optional free rapid HIV test. Multivariate regression analysis was used to examine demographic correlates of unprotected anal sex and any history of HIV testing. Nearly half (47 %) were under age 25 years and 67 % self-identified as gay. Nearly two-thirds (64 %) reported any unprotected anal intercourse (UAI) with men in the prior 3 months, including 23 % who had unprotected anal intercourse with men whose HIV status was positive or unknown (UAIPU) to the participant. Three men (1.5 % of 198 participants tested) were HIV-positive; 62 % had any history of HIV testing prior to the study and testing was less common among those engaging in UAIPU compared to others (33 % vs. 71 %). In regression analysis, men in a relationship had higher odds of having UAI but lower odds of UAIPU and any university education was associated with having UAI; those with any prior history of HIV testing were more likely to be in a relationship and have any university education. HIV prevention efforts for MSM need to account for the influence of relationship dynamics and promotion of testing needs to target high-risk MSM.

Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods study

BACKGROUND

There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.

METHODS AND FINDINGS

Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.

CONCLUSIONS

The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.

Community viral load and CD4 count distribution among people living with HIV in a South African Township: implications for treatment as prevention

INTRODUCTION

The goals of scale-up of antiretroviral therapy (ART) have expanded from prevention of morbidity and death to include prevention of transmission. Morbidity and mortality risk are associated with CD4 count; transmission risk depends on plasma viral load (VL). This study aimed to describe CD4 count and VL distributions among HIV-infected individuals in a South African township to gain insights into the potential impact of ART scale-up on community HIV transmission risk.

METHODS

A random sample of 10% of the adult population was invited to attend an HIV testing service. Study procedures included a questionnaire, HIV testing, CD4 count, and VL testing.

RESULTS

One thousand one hundred forty-four (88.0%) of 1300 randomly selected individuals participated in the study. Two hundred sixty tested positive, giving an HIV prevalence of 22.7% [95% confidence interval (CI): 20.3 to 25.3]. A third of all HIV-infected individuals (33.5%, 95% CI: 27.8 to 39.6) reported taking ART. The median CD4 count was 417 cells per microliter (interquartile range, 285-627); 33 (12.7%, 95% CI: 8.9 to 17.4) had a CD4 count of ≤200 cells per microliter. VL measurements were available for 219 individuals (84.2%) and were undetectable in 72 (33.9%), >1500 copies per milliliter in 127 (58.0%) and >10,000 copies per milliliter in 96 (43.8%). Of those reporting they were receiving ART, 30.4% had a VL >1500 copies per milliliter compared with 58.0% of those reporting they were not receiving ART.

CONCLUSIONS

A small proportion of those living with HIV in this community had a CD4 count of <200 cells per microliter; more than half had a VL high enough to be associated with considerable transmission risk. A substantial proportion of HIV-infected individuals remained at risk of transmitting HIV even after starting ART.

Differences in testing, stigma, and perceived consequences of stigmatization among heterosexual men and women living with HIV in Bengaluru, India

Approximately 2.4 million people in India are living with HIV. Gender inequality affects HIV prevention, detection, and management. The purpose of this paper was to describe gender differences in the experience of living with HIV in Bengaluru, India. A subsample of n = 313 (159 men and 154 women) from a larger cohort was used for these analyses. Participants were recruited through AIDS service organizations. They completed an interviewer-administered survey assessing HIV testing experience, types of stigma, and perceived consequences of stigmatization. The majority of men (67%) reported getting HIV tested because of illness, while women were more likely to be tested after learning their spouse's HIV-positive status (42%). More men (59%) than women (45%, p<0.05) were tested in private care settings. Men reported significantly higher mean levels of internalized stigma (men: M=0.71, SD = 0.63; women: M=0.46, SD = 0.55; p<0.001), whereas the women reported significantly higher scores for enacted stigma (men: M=1.30, SD = 1.69; women: M=2.10, SD = 2.17; p<0.001). These differences remained significant after controlling for potential socio-demographic covariates. Following their diagnosis, more women reported moving out of their homes (men: 16%; women: 26%; p<0.05). More men (89%) than women (66%; p<0.001) reported to have modified their sexual behavior after being diagnosed. These findings suggest that the experience of living with HIV and HIV stigma varies by gender in this population. Suggestions for a gender-based approach to HIV prevention and stigma reduction are provided.

HIV-related travel restrictions: trends and country characteristics

Introduction

Increasingly, HIV-seropositive individuals cross international borders. HIV-related restrictions on entry, stay, and residence imposed by countries have important consequences for this mobile population. Our aim was to describe the geographical distribution of countries with travel restrictions and to examine the trends and characteristics of countries with such restrictions.

Methods

In 2011, data presented to UNAIDS were used to establish a list of countries with and without HIV restrictions on entry, stay, and residence and to describe their geographical distribution. The following indicators were investigated to describe the country characteristics: population at mid-year, international migrants as a percentage of the population, Human Development Index, estimated HIV prevalence (age: 15–49), presence of a policy prohibiting HIV screening for general employment purposes, government and civil society responses to having non-discrimination laws/regulations which specify migrants/mobile populations, government and civil society responses to having laws/regulations/policies that present obstacles to effective HIV prevention, treatment, care, and support for migrants/mobile populations, Corruption Perception Index, and gross national income per capita.

Results

HIV-related restrictions exist in 45 out of 193 WHO countries (23%) in all regions of the world. We found that the Eastern Mediterranean and Western Pacific Regions have the highest proportions of countries with these restrictions. Our analyses showed that countries that have opted for restrictions have the following characteristics: smaller populations, higher proportions of migrants in the population, lower HIV prevalence rates, and lack of legislation protecting people living with HIV from screening for employment purposes, compared with countries without restrictions.

Conclusion

Countries with a high proportion of international migrants tend to have travel restrictions – a finding that is relevant to migrant populations and travel medicine providers alike. Despite international pressure to remove travel restrictions, many countries continue to implement these restrictions for HIV-positive individuals on entry and stay. Since 2010, the United States and China have engaged in high profile removals. This may be indicative of an increasing trend, facilitated by various factors, including international advocacy and the setting of a UNAIDS goal to halve the number of countries with restrictions by 2015.

Women experience a better long-term immune recovery and a better survival on HAART in Lao People's Democratic Republic

Background

In April 2003, Médecins Sans Frontières launched an HIV/AIDS programme to provide free HAART to HIV-infected patients in Laos. Although HIV prevalence is estimated as low in this country, it has been increasing in the last years. This work reports the first results of an observational cohort study and it aims to identify the principal determinants of the CD4 cells evolution and to assess mortality among patients on HAART.

Methods

We performed a retrospective database analysis on patients initiated on HAART between 2003 and 2009 (CD4<200cells/μL or WHO stage 4). We excluded from the analysis patients who were less than 16 years old and pregnant women. To explore the determinants of the CD4 reconstitution, a linear mixed model was adjusted. To identify typical trajectories of the CD4 cells, a latent trajectory analysis was carried out. Finally, a Cox proportional-hazards model was used to reveal predictors of mortality on HAART including appointment delay greater than 1 day.

Results

A total of 1365 patients entered the programme and 913 (66.9%) received an HAART with a median CD4 of 49 cells/μL [IQR 15–148]. High baseline CD4 cell count and female gender were associated with a higher CD4 level over time. In addition, this gender difference increased over time. Two typical latent CD4 trajectories were revealed showing that 31% of women against 22% of men followed a high CD4 trajectory. In the long-term, women were more likely to attend appointments without delay. Mortality reached 6.2% (95% CI 4.8-8.0%) at 4 months and 9.1% (95% CI 7.3-11.3%) at 1 year. Female gender (HR=0.17, 95% CI 0.07-0.44) and high CD4 trajectory (HR=0.19, 95% CI 0.08-0.47) were independently associated with a lower death rate.

Conclusions

Patients who initiated HAART were severely immunocompromised yielding to a high early mortality. In the long-term on HAART, women achieved a better CD4 cells reconstitution than men and were less likely to die. This study highlights important differences between men and women regarding response to HAART and medical care, and questions men’s compliance to treatment.

Male involvement for increasing the effectiveness of prevention of mother-to-child HIV transmission (PMTCT) programmes

BACKGROUND

Despite efforts to increase the uptake of prevention of mother to child transmission of HIV (PMTCT) services, coverage is still lower than desired in developing countries. A lack of male partner involvement in PMTCT services is a major barrier for women to access these services.

OBJECTIVES

To evaluate the impact of interventions which aim to enhance male involvement to increase women's uptake of PMTCT interventions in developing countries.

SEARCH METHODS

We searched the following databases from the year 2000 to November 2011: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, the WHO Global Health Library, ClinicalTrials.gov, Current Controlled Trials, AEGIS, CROI, IAS, IAC web sites.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-randomised controlled trials, quasi-randomised controlled trials, controlled before and after studies and interrupted time series studies assessing interventions to increase male involvement for improvement of uptake PMTCT services in low- and middle-income countries..

DATA COLLECTION AND ANALYSIS

Two reviewers independently searched, screened, assessed study quality and extracted data. A third reviewer resolved any disagreement.

MAIN RESULTS

Only one study met the inclusion criteria, an RCT conducted in Tanzania between May 2003 and October 2004. Women in the intervention group (n=760) received a letter for their male partners, which invited them to return together to receive Couple Voluntary Counselling and Testing (CVCT) for HIV. Women in the control group (n=761) received individual HIV VCT during their first ANC visit and then usual care. The percentages of women who received HIV VCT and collected their results were 48%, 45% and 39% in the intervention group and 93%, 78% and 71% in the control group (p <0,001). Only 33% of women in the intervention group returned with their male partners and only 47% of them went through the whole CVCT process. The proportion of women who received HIV prophylaxis at delivery was not different between the two arms (27% in the intervention and 22% in the control group). The study had a high risk of bias.  

AUTHORS' CONCLUSIONS

We found only one eligible study that assessed the effectiveness of male involvement in improving women's uptake of PMTCT services, which only focused on one part of the perinatal PMTCT cascade. We urgently need more rigorously designed studies assessing the impact of male engagement interventions on women's uptake of PMTCT services to know if this intervention can contribute to improve uptake of PMTCT services and reduce vertical transmission of HIV in children.   

Who is utilizing anti-retroviral therapy in Ghana: an analysis of ART service utilization

INTRODUCTION

The global scale-up of antiretroviral therapy (ART) for HIV patients has led to concerns regarding inequities in utilization of ART services in resource-limited contexts. In this paper, we describe regional and sex differentials in the distribution of ART among adult HIV patients in Ghana. We highlight the need for interventions to address the gender-based and geographic inequities related to the utilization of ART services in Ghana.

METHODS

We reviewed National AIDS/STIs Control Program's ART service provision records from January 2003 through December 2010, extracting data on adults aged 15+ who initiated ART in Ghana over a period of eight years. Data on the number of patients on treatment, year of enrollment, sex, and region were obtained and compared.

RESULTS

The number of HIV patients receiving ART in Ghana increased more than 200-fold from 197 in 2003, to over 45,000 in 2010. However, for each of six continuous years (2005-2010) males comprised approximately one-third of adults newly enrolled on ART. As ART coverage has expanded in Ghana, the proportion of males receiving ART declined from 41.7% in 2004 to 30.1% in 2008 and to 27.6% in 2010. Also, there is disproportionate regional ART utilization across the country. Some regions report ART enrollment lower than their percent share of number of HIV infected persons in the country.

CONCLUSIONS

Attention to the comparatively fewer males initiating ART, as well as disproportionate regional ART utilization is urgently needed. All forms of gender-based inequities in relation to HIV care must be addressed in order for Ghana to realize successful outcomes at the population level. Policy makers in Ghana and elsewhere need to understand how gender-based health inequities in relation to HIV care affect both men and women and begin to design appropriate interventions.

A qualitative exploration of sexual risk and HIV testing behaviors among men who have sex with men in Beirut, Lebanon

Men who have sex with men (MSM) may account for most new HIV infections in Lebanon, yet little is known about the factors that influence sexual risk behavior and HIV testing in this population. Qualitative interviews were conducted with 31 MSM living in Beirut, and content analysis was used to identify emergent themes. Mean age of the participants was 28.4 years, and all identified as either gay (77%) or bisexual (23%). Half reported not using condoms consistently and one quarter had not been HIV-tested. Many described not using condoms with a regular partner in the context of a meaningful relationship, mutual HIV testing, and a desire to not use condoms, suggesting that trust, commitment and intimacy play a role in condom use decisions. Condoms were more likely to be used with casual partners, partners believed to be HIV-positive, and with partners met online where men found it easier to candidly discuss HIV risk. Fear of infection motivated many to get HIV tested and use condoms, but such affect also led some to avoid HIV testing in fear of disease and social stigma if found to be infected. Respondents who were very comfortable with their sexual orientation and who had disclosed their sexuality to family and parents tended to be more likely to use condoms consistently and be tested for HIV. These findings indicate that similar factors influence the condom use and HIV testing of MSM in Beirut as those observed in studies elsewhere of MSM; hence, prevention efforts in Lebanon can likely benefit from lessons learned and interventions developed in other regions, particularly for younger, gay-identified men. Further research is needed to determine how prevention efforts may need to be tailored to address the needs of men who are less integrated into or do not identify with the gay community.

Revisiting long-term adherence to highly active antiretroviral therapy in Senegal using latent class analysis

BACKGROUND

Adherence is one of the main predictors of antiretroviral treatment success. A governmental initiative was launched in 1998 for HIV-infected patients in Senegal to provide access to highly active antiretroviral therapy.

METHODS

Between August 1998 and April 2002, 404 adult patients were enrolled. Adherence measurements, defined as pills taken/pills prescribed, were assessed between November 1999 and April 2009 using a pill count along with a questionnaire for 330 patients. Predictors of adherence were explored through a random-intercept Tobit model and a latent class analysis (LCA) was performed to identify adherence trajectories. We also performed a survival analysis taking into account gender and latent adherence classes.

RESULTS

Median treatment duration was 91 months (interquartile range, 84-101). On average, adherence declined by 7% every year, was 30% lower for patients taking indinavir, and 12% higher for those receiving cotrimoxazole prophylaxis. Based on the predicted probability of having an adherence ≥ 95%, LCA revealed 3 adherence behaviors and a better adherence for women. A quarter of patients had a high adherence trajectory over time and half had an intermediate one. Male gender and low adherence behavior over time were independently associated with a higher mortality rate.

CONCLUSIONS

This study shows that an overall good adherence can be obtained in the long term in Senegal. LCA suggests a better adherence for women and points out a large subsample of patients with intermediate level of adherence behavior who are at risk for developing resistance to antiretroviral drugs. This study warrants further research into gender issues.

Reproductive health for refugees by refugees in Guinea IV: Peer education and HIV knowledge, attitudes, and reported practices

BACKGROUND

Both conflict and HIV affect sub-Saharan Africa, and supportive approaches for HIV prevention among refugees are crucial. Peer education has been associated with improved HIV outcomes, though relatively little research has been published on refugee settings. The primary objective of this study was to assess whether exposure to refugee peer education was associated with improved HIV knowledge, attitudes, or practice outcomes among refugees in Guinea. Secondary objectives were to assess whether gender, age, or formal education were more strongly associated than peer education with improved HIV outcomes.

METHODS

Data was collected by cross-sectional survey from 889 reproductive-age men and women in 23 camps in the Forest Region of Guinea. Selected exposures (i.e. peer education, gender, formal education, age) were analysed for associations with HIV outcomes using logistic regression odds ratios (OR).

RESULTS

Most participants (88%) had heard of HIV, particularly those exposed to peer or formal education. Most correctly identified ways to protect themselves, while maintaining misconceptions about HIV transmission. Women and those exposed to either peer or formal education had significantly fewer misconceptions. Half of participants considered themselves at risk of HIV, women with 52% higher odds than men (adjusted OR 1.52, 95%CI 1.01-2.29). Participants exposed to peer education had more than twice the odds of reporting having made HIV-avoidant behavioural changes than unexposed participants (72% versus 58%; adjusted OR 2.49, 95%CI 1.52-4.08). While women had 57% lower odds than men of reporting HIV-avoidant behavioural changes (OR 0.43, 95%CI 0.31-0.60), women exposed to peer education had greater odds than exposed men of reporting HIV-avoidant changes (OR 2.70 versus OR 1.95). Staying faithful (66%) was the most frequent behavioural change reported.

CONCLUSIONS

Peer education was most strongly associated with reported HIV-avoidant behaviour change. Gender was most associated with HIV knowledge and risk perception. Refugee women had fewer misconceptions than men had, but were more likely to report HIV risk and less likely to report making behavioural changes. Peer education appears promising for HIV interventions in chronic-emergency settings, if gender disparities and related barriers to condom usage are also addressed.

Economic Status and Coping Mechanisms of Individuals Seeking HIV Care in Uganda

This study uses novel data to conduct a comprehensive evaluation of the demographic and economic circumstances facing HIV-positive individuals who have just entered HIV care in Uganda. While the provision of HIV care and antiretroviral therapy (ART) may improve physical health, to achieve the broader goal of improving the quality of life and socioeconomic viability of people living with HIV/AIDS, appropriate social and economic programmes may need to complement treatment. We report results from baseline data of a longitudinal, prospective cohort study with a 12-month follow-up period in two Ugandan HIV clinics. We use t-tests to examine differences across sample subpopulations and in a second step employ multivariate logistic and ordinary least squares regressions. The investigation of retrospective variables such as the respondent's employment and income history, as well as changes in household composition, allows us to draw conclusions about the shocks experienced by households with HIV-positive members. We find that the study participants have experienced job loss and declining household income since testing HIV-positive, mainly due to worsened health status of the respondent. We also find that households use a range of coping mechanisms, such as changes in household composition or borrowing in response to these shocks, but that these strategies are not accessible to all types of households to the same degree. The findings highlight the importance of ART, not only to improve physical health, but also as a first necessary (though potentially not sufficient) step to help households restore their economic capacity.

Barriers to gender-equitable HIV testing: going beyond routine screening for pregnant women in Nova Scotia, Canada

BACKGROUND

Women and men face different gender-based health inequities in relation to HIV, including HIV testing as well as different challenges in accessing HIV care, treatment and support programs and services when testing HIV-positive. In this article, we discuss the findings of a mixed methods study exploring the various individual and structural barriers and facilitators to HIV counselling and testing experienced among a sample of adult women and men living in Nova Scotia, Canada.

METHODS

Drawing from testing demographics, qualitative interview data and a review of existing testing policies and research, this paper focuses on understanding the gendered health inequities and their implications for HIV testing rates and behaviours in Nova Scotia.

RESULTS

The findings of this research serve as the basis to further our understanding of gender as a key determinant of health in relation to HIV testing. Recognizing gender as a key determinant of health in terms of both vulnerability to HIV and access to testing, this paper explores how gender intersects with health equity issues such as access to HIV testing, stigma and discrimination, and sexual behaviours and relationships.

CONCLUSIONS

Drawing on the current gender and HIV literatures, in conjunction with our data, we argue that an enhanced, gender-based, context-dependent approach to HIV counselling and testing service provision is required in order to address the health equity needs of diverse groups of women and men living in various settings. Further, we argue that enhanced HIV testing efforts must be inclusive of both men and women, addressing uniquely gendered barriers to accessing HIV counselling and testing services and in the process moving beyond routine HIV testing for pregnant women.

Antiretroviral therapy: unmet need and associated socio-demographic characteristics among HIV-positive women in Haiphong, Vietnam

In Vietnam, ARV access has been scaled up since 2005 in high HIV prevalence areas in order to meet increasing demands for HIV treatment. This paper aims to estimate ARV unmet need and its associated socio-demographic characteristics among HIV-positive women in Haiphong, Vietnam. A cross-sectional study using structured questionnaires and CD4 cell count was conducted with 353 HIV-positive women recruited from groups of people living with HIV/AIDS (PLWHA), by snowball technique through member of PLWHA groups and the local AIDS management system (Provincial AIDS Center (PAC)). The percentage of HIV-positive women having an unmet ARV need was estimated to be 40%, particularly high among women who were not registered at PAC. Having an unmet ARV need was associated with not participating in PLWHA groups (OR 6.5; 2.4-17.2) and being younger than 30 years old (OR 2.9; 1.1-7.3).

A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting

BACKGROUND

The objectives of this study were to examine the determinants of using a peer-led mobile outreach program (the Mobile Access Project [MAP]) among a sample of street-based female sex workers (FSWs) who use drugs in an urban Canadian setting and evaluate the relationship between program exposure and utilizing addiction treatment services.

METHODS

A detailed questionnaire was administered at baseline and bi-annual follow-up visits over 18 months (2006-2008) to 242 FSWs in Vancouver, Canada. We used bivariate and multivariate logistic regression with generalized estimating equations for both objectives, reporting unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals (CIs).

RESULTS

Over 18 months, 42.2% (202) reports of peer-led mobile outreach program use were made. High-risk women, including those servicing a higher weekly client volume (10+ compared to <10; AOR: 1.7, 95%CIs: 1.1-2.6) and those soliciting clients in deserted, isolated settings (AOR: 1.7, 95%CIs: 1.1-2.7) were more likely to use the program. In total, 9.4% (45) reports of using inpatient addiction treatment services were made (7.5% detoxification; 4.0% residential drug treatment), and 33.6% (161) using outpatient treatment (28.8% methadone; 9.6% alcohol/drug counsellor). Women who used the peer-led mobile outreach were more likely to use inpatient addiction treatment (AOR: 4.2, 95%CIs: 2.1-8.1), even after adjusting for drug use, environmental-structural factors, and outpatient drug treatment.

DISCUSSION

Our findings demonstrate that FSWs at higher risk for sexually transmitted infections and violence are more likely to access this peer-led mobile outreach program and suggest that the program plays a critical role in facilitating utilization of detoxification and residential drug treatment.