From activism to secrecy: Contemporary experiences of living with HIV in London in people diagnosed from 1986 to 2014

Asked to be a sperm donor: disclosure dilemmas of gay men living with HIV

Previous research has documented the various challenges people living with HIV face as they navigate intimate relationships, including what is often referred to as disclosure. In studies of gay, bisexual and other men who have sex with men, the issue of telling or not telling others about an HIV-positive status has been examined primarily in relation to communication with sexual partners, with few studies focusing on other aspects of intimacy. Drawing on interviews with gay men living with HIV, conducted in four clinics in London, this article explores the narratives of men who have been asked by female friends about the possibility of being a sperm donor. The narratives highlight layers of complexity which have received little attention, not only in research on HIV but also in studies of sperm donation and co-parenting. The article advances dialogue between these two largely separate bodies of work. Our data suggest that reluctance to share an HIV-positive status with others can be an important factor in deciding how to answer the 'sperm donor question'. Examining reproductive relationships of a specific kind - those based on friendships between women and gay men - the article develops the understanding of how secrecy about HIV shapes intimate lives.

The experienced positive and negative influence of HIV on quality of life of people with HIV and vulnerable to HIV in the Netherlands

This qualitative study aimed to explore the experienced influence of HIV on the quality of life (QoL) of people with HIV (PHIV) and key populations without but are vulnerable to HIV in the Netherlands. We conducted and thematically analyzed interviews with 29 PHIV and 13 participants from key populations without HIV (i.e., men who have sex with men). PHIV and key populations shared positive meaningful experiences regarding HIV, i.e., feeling grateful for ART, life, and the availability of PrEP, being loved and supported in the light of HIV, and providing support to the community. Negative predominant experiences regarding HIV were described by both PHIV and key populations as the negative effects of ART, challenges with regards to disclosing HIV, social stigmatization, and self-stigma. It remains important to support HIV community organizations in their efforts to reduce social stigmatization and to continue improving biomedical interventions for HIV.

HIV Health literacy beyond the biomedical model: an innovative visual learning tool to highlight the psychosocial complexities of care

The HIV care continuum represents a linear clinical pathway from testing to viral suppression; however, it does not capture the psychosocial complexities of contemporary HIV care. We developed an innovative and appealing visual learning resource to extend the scope of HIV health literacy beyond biomedical constructs. Based on the lived experiences of recently diagnosed people living with HIV in Queensland, the "Journeys through the HIV Care Continuum" Map presents the continuum as a complex journey incorporating challenges such as poor health literacy, health service access and stigma alongside facilitators to care, including emotional and peer support. Designed for audiences who may not access academic literature, the Map can be used to facilitate conversations between recently diagnosed people living with HIV and peer navigators, and as a learning tool for health professionals, carers and students. The Map highlights opportunities to support PLHIV in meaningful ways that will reduce stigma and promote care access.

Understanding the Social and Emotional Dimensions of HIV Self-Management: A Qualitative Study of Newly Diagnosed People Living With HIV in Queensland, Australia

ABSTRACT

Understanding of HIV self-management increasingly focuses on treatment adherence and associated health-related behaviors, yet people living with HIV (PLWH) seldom perform these actions in a social vacuum. Thus, delivering comprehensive self-management support programs for PLWH requires an understanding of the social and emotional dimensions of HIV self-management. Through thematic analysis of in-depth interviews with 35 newly diagnosed PLWH, this descriptive qualitative study highlights these dimensions and their effect on experiences of HIV diagnosis and care. HIV self-management involves interpersonal interactions that affect efforts to seek support and reimagine one's personal identity in a changed reality. Managing disclosures and navigating stigma constitute everyday work for many PLWH. Because stigma continues to impede care engagement and well-being for PLWH, health practitioners must extend focus beyond viral suppression and prioritize support for emotional and social self-management. Nurses can create safe, nonstigmatizing spaces for conversations about HIV, uphold the rights of PLWH around disclosure, and ensure that PLWH are connected to peer support services.

The perceived impact of an HIV cure by people living with HIV and key populations vulnerable to HIV in the Netherlands: A qualitative study

Introduction

When an HIV cure becomes available, it will have consequences for people living with HIV (PLHIV) and key populations who are vulnerable to HIV. This qualitative study aimed to explore the perceived impact of two HIV cure scenarios (post-treatment control when HIV is suppressed without the need for ongoing antiretroviral treatment (ART) and complete HIV elimination) on the quality of life of PLHIV and key populations living without HIV in the Netherlands.

Methods

Participants were purposefully sampled from the Amsterdam Cohort Studies, the AGEhIV Cohort Study, the outpatient clinic of the University Medical Centre Utrecht and the Dutch HIV Association to increase variability. Semi-structured in-depth interviews were conducted between October 2020 and March 2021 and thematically analysed.

Results

Of the 42 interviewed participants, 29 were PLHIV and 13 represented key populations (i.e., men who have sex with men and people injecting drugs). Both PLHIV and participants from vulnerable key populations hoped that a cure would result in normalization of their lives by removing the need to disclose HIV, reducing stigma and guilt, increasing independence of ART, and liberating sexual behaviour. Both groups believed only HIV elimination could accomplish this desired impact.

Conclusions

While the post-treatment control scenario seems a more plausible outcome of current HIV cure research, our findings highlight that participants may not perceive it as a true cure. Involvement of PLHIV and vulnerable key populations in devising acceptable and feasible experimental approaches to HIV cure is essential to ensure their future successful implementation.

The Burden of Living With HIV is Mostly Overestimated by HIV-Negative and Never-Tested Men Who Have Sex With Men

To assess whether HIV-negative men who have sex with men (MSM) have realistic views of the current implications of living with HIV, we compared data of 950 tested HIV-negative and 122 never-tested MSM on anticipated consequences of an HIV-infection to the actual experiences of 438 MSM living with HIV. Data were collected with a self-reported, web-based survey conducted between May-June 2019 in the Netherlands. Results indicated that, compared to HIV-positive MSM, HIV-negative MSM significantly overestimated 95% (37/39) of items assessing HIV-related burden. Never-tested participants overestimated 85% (33/39) of items. Overestimation in never-tested MSM was modified with increasing age and having HIV-positive friends/relatives. The high level of overestimation suggests the ongoing need to correct for misperceptions, as this could help reduce stigma towards those living with HIV and diminish fear of an HIV-diagnosis. The latter might be important to improve testing uptake in older never-tested MSM with outdated views on HIV.

Towards a new understanding of HIV-related stigma in the era of efficient treatment- A qualitative reconceptualization of existing theory

AIM

To further develop Earnshaw and Chaudoir's HIV stigma framework by describing the experiences of HIV-related stigma among people living with viral suppression in a context where HIV is well controlled and to investigate how these experiences correspond to the stigma mechanisms of the framework.

DESIGN

Qualitative study using interviews and a framework approach to analysis.

METHODS

People living with virally suppressed HIV in Sweden were recruited through an outpatient clinic and interviewed about their experiences of social aspects of living with HIV. The interviews were audio recorded, transcribed and analysed using a framework approach.

RESULTS

Fifteen participants (eight women and seven men, aged 30-64 years) were interviewed from March to September 2017. They described stigma around HIV as a barrier in many situations. Anticipated and enacted stigma were found to be more complex than is described in the existing literature. Being labelled as a person with HIV was found to be an important and persistent part of the stigma experience. Disclosure was found to be context-related and a result of a process of negotiating and weighing the relevance of disclosing HIV, perceiving HIV as a private matter and feeling a responsibility to disclose one's HIV status to others. An important reason for nondisclosure was to avoid being labelled with HIV, which would then become their most defining feature.

CONCLUSIONS

The HIV stigma framework could benefit from revision for people living with virally suppressed HIV.

IMPLICATIONS

The present findings, which indicate the role of health professionals in relation to disclosure and labelling, may guide nurses and other healthcare personnel in providing counselling and support for people who live with virally suppressed HIV and experience stigma.

Can HIV-positive gay men become parents? How men living with HIV and HIV clinicians talk about the possibility of having children

It is now established that people living with HIV who have an undetectable viral load and adhere to antiretroviral treatment cannot transmit HIV to their sexual partners. Previous research has shown that 'being undetectable' changes how HIV-positive gay men experience their sex lives. But how does it affect gay men's reproductive behaviours? And what influence does it have on views about parenthood at a time when gay fatherhood has become more socially accepted and publicly visible? Drawing on qualitative interviews with patients and clinicians at four HIV clinics in London, we identify differences in how interviewees talked about the possibility of having children for HIV-positive men. Both groups, unprompted, frequently referred to sperm washing as a method enabling safe conception. However, whereas clinicians talked about sperm washing as an historical technique, which is no longer necessary, patients spoke of it as a current tool. The men rarely mentioned being undetectable as relevant to parenthood and, when prompted, some said that they did not fully understand the mechanics of HIV transmission. Our findings offer new insights into how biomedical knowledge is incorporated into people's understandings of living with HIV, raising important questions about how the meanings of being undetectable are communicated.

Burden of living with HIV among men who have sex with men: a mixed-methods study

BACKGROUND

With biomedical developments in treatment and prevention of HIV, the implications of living with HIV are considerably more manageable. Within this context, we aimed to describe and quantify the present-day burden of living with HIV among men who have sex with men (MSM) in the Netherlands.

METHODS

In this mixed-methods study, we did in-depth interviews on HIV-related burden with MSM diagnosed with HIV between 2014 and 2018. Interviewees were recruited at three HIV treatment centres and the Public Health Service of Amsterdam in the Netherlands. Using the transcripts from all interviewees, the qualitative analysis was done by two independent researchers applying an open-coding process. Results were used to generate a questionnaire measuring HIV-related burden, which was distributed via gay dating apps or sites and social media. MSM diagnosed with HIV before 2019 who completed the questionnaire were included in the quantitative analyses. Descriptive analyses were used to report burden prevalence and to explore differences in burden among MSM diagnosed at different antiretroviral therapy periods. Sociodemographic determinants of burden were explored using multinomial logistic regression.

FINDINGS

Between May, 2018, and March, 2019, 18 of 25 MSM who consented for further contact were interviewed, after which thematic saturation was reached. The interviewees revealed that aspects related to medicalisation and emotional consequences were burdensome temporarily after diagnosis, whereas aspects related to HIV status disclosure, stigma, and the sexual and social life were mentioned to be burdensome more persistently. Between April and July, 2019, 613 MSM with HIV started the quantitative survey, of whom 438 (71%) completed the questionnaire and were included in the analyses. These 438 MSM were diagnosed with HIV between 1984 and 2018. The median time since HIV diagnosis was 8 years (IQR 4-13). In total, 135 (31%) of 438 online respondents reported that living with HIV was generally experienced as burdensome and 361 (82%) would be relieved if HIV could be cured. Compared with a low level of burden, a moderate level of burden was associated with having another chronic condition (p=0·0030), and a high level of burden was associated with a more recent diagnosis (p=0·0060) and not knowing other individuals with HIV (p=0·0020). Disclosure dilemmas were reported to be the most burdensome, resulting in difficulties initiating sex (122 [32%] of 378 respondents) and establishing relationships (85 [41%] of 207 respondents). The most prevalent emotional consequences were shame (112 [26%] of 438 respondents) and stress (80 [18%] of 438 respondents). Disclosure and taking antiretroviral therapy in the presence of others were experienced as more burdensome among those diagnosed after 2005 than among those diagnosed in or before 2005.

INTERPRETATION

Our findings highlight that despite medical advancements, further stigma reduction programmes and adapted psychosocial support for specific profiles of MSM living with HIV are needed.

FUNDING

HIV Transmission Elimination Amsterdam Initiative.

The Changing Narratives of Death, Dying, and HIV in the United Kingdom

Death and infection were closely linked from the start of the HIV epidemic, until successful treatments became available. The initial impact of mostly young, gay men dying from HIV was powerful in shaping UK responses. Neoliberal discourses developed at the same time, particularly focusing on how citizens (rather than the state) should take responsibility to improve health. Subsequently "successful ageing" became an allied discourse, further marginalising death discussions. Our study reflected on a broad range of meanings around death within the historical UK epidemic, to examine how dying narratives shape contemporary HIV experiences. Fifty-one participants including people living with HIV, professionals, and activists were recruited for semistructured interviews. Assuming a symbolic interactionist framework, analysis highlighted how HIV deaths were initially experienced as not only traumatic but also energizing, leading to creativity. With effective antiretrovirals, dying changed shape (e.g., loss of death literacy), and better integration of palliative care was recommended.

Holding Secrets While Living With Life-Threatening Illness: Normalizing Patients' Decisions to Reveal or Conceal

Communicating openly and directly about illness comes easily for some patients, whereas for others fear of disclosure keeps them silent. In this article, we discuss findings about the role of keeping secrets regarding health and illness. These findings were part of a larger project on how people with life-threatening illnesses re-story their lives. A narrative approach drawing on Frank's dialogical narrative analysis and Riesman's inductive approach was used. Interviews were conducted with 32 participants from three populations: chronic kidney disease, HIV/AIDS, and cancer. Findings include case exemplars which suggest keeping secrets is a social practice that acts along continuums of connecting-isolating, protecting-harming, and empowering-imprisoning. Keeping secrets about illness is a normative practice that is negotiated with each encounter. Findings call health-care providers to rethink the role of secrets for patients by considering patient privilege, a person's right to take the lead in revealing or concealing their health and illness experience.

Experience of primary care for people with HIV: a mixed-method analysis

BACKGROUND

Advances in treatment have transformed HIV into a long-term condition (LTC), presenting fresh challenges for health services, HIV specialists, and GPs.

AIM

To explore the experience of people living with HIV (PLHIV) regarding consulting their GPs.

DESIGN & SETTING

A mixed-method analysis using data from two sources: a nationally-representative survey of PLHIV and a qualitative study with London-based PLHIV.

METHOD

Univariate logistic regression was used for quantitative data and framework analysis for qualitative data.

RESULTS

The survey had 4422 participants; the qualitative study included 52 participants. In both studies, registration with a GP and HIV status disclosure were high. Similar to general population trends, recent GP use was associated with poor self-rated health status, comorbidities, older age, and lower socioeconomic status. Two-thirds reported a good experience with GPs; a lower proportion felt comfortable asking HIV-related questions. Actual or perceived HIV stigma were consistently associated with poor satisfaction. In the interviews, participants with additional LTCs valued sensitive and consistent support from GPs. Some anticipated, and sometimes experienced, problems relating to HIV status, as well as GPs' limited experience and time to manage their complex needs. Sometimes they took their own initiative to facilitate coordination and communication. For PLHIV, a 'good' GP offered continuity and took time to know and accept them without judgment.

CONCLUSION

The authors suggest clarification of roles and provision of relevant support to build the confidence of PLHIV in GPs and primary care staff to care for them. As the PLHIV population ages, there is a strong need to develop trusting patient-GP relationships and HIV-friendly GP practices.

"I have HIV but I'm not the HIV" - the experiences of heterosexual Chinese men living with HIV in Singapore

As HIV is widely acknowledged as a stigmatized chronic condition which impacts the self, it is important to study the experiences of people living with HIV in relation to their selves and identities. According to extant literature on HIV and identity, the incorporation of an HIV identity is essential to adapting to the diagnosis. However, most of the participants in this study reject HIV as an identity. Using qualitative in-depth interviews, this paper explores the experiences of twelve heterosexual Chinese men living with HIV in Singapore. This paper is anchored by identity concepts from identity theory to examine the impact of HIV on self and identities and how various identities are reworked in the face of a stigmatized chronic medical condition. Thematic analysis shows varying impact of HIV on self, the role of normative identities and the location of HIV in their lives. The findings shed light on the importance of normative identities and the manner in which participants locate HIV in their lives.

From activism to secrecy: Contemporary experiences of living with HIV in London in people diagnosed from 1986 to 2014

Background

Successes in biomedicine have transformed HIV from a debilitating and frequently fatal infection to a chronic, manageable condition.

Objective

To explore how the contemporary metanarrative of HIV as a chronic condition is understood by patients and how it varies depending on when they were diagnosed.

Design

Qualitative interviews with 52 people living with HIV who were diagnosed during different phases in the history of the epidemic.

Setting and participants

Participants were recruited from two HIV clinics in London to include four “HIV generations”: generation 1 were those who had been diagnosed pre‐1997 (pre‐ART), generation 2 from 1997 to 2005 (complex ART), generation 3 from 2006 to 2012 (simpler ART) and generation 4 diagnosed in the year before the study (2013‐2014).

Results

Participants in all HIV generations took their medication as prescribed, attended clinic appointments and were well informed about their immunological biomarkers. While the pre‐treatment generation had been engaged in community endeavours such as activism, public education and use of support groups, those more recently diagnosed had little experience of collective activities and their HIV was essentially a private matter, separate from their social identity. These strategies worked for some; however, those experiencing clinical or social problems related to HIV or wider issues often relied exclusively on their HIV clinic for wider support.

Conclusion

The loss of public conversation around HIV, the imperative for patients to take on greater individual responsibility for HIV management and the streamlining of HIV services alongside reductions in ancillary support services may expose some people to suboptimal health outcomes.