Verbal and Physical Abuse and Neglect as Manifestations of HIV/AIDS Stigma in Five African Countries

Physician-Patient Interaction Quality Mediates the Association Between HIV-Related Stigma and HIV-Prevention Behaviors Among Sexual Minority Men in Zambia

HIV-related stigma is a major challenge to HIV prevention for sexual minority men (SMM) in Zambia, but little is known about the underlying mechanisms. This study aimed to investigate whether physician-patient interaction quality mediates the relationship between HIV-related stigma and HIV-prevention behaviors among SMM. Data were collected using a cross-sectional survey from 194 SMM (aged: mean = 24.08, SD = 4.27) across four districts in Zambia between February and November 2021. Participants were asked about their demographic characteristics, HIV-related stigma, SMM-related stigma, physician-patient interaction quality, HIV-testing intention, and use of pre-exposure prophylaxis (PrEP). Path analysis was used to test the mediation effect of physician-patient interaction quality in the associations of HIV-related stigma/SMM-related stigma with HIV-testing intention and current PrEP use. Higher self-reported physician-patient interaction quality was negatively associated with HIV-related stigma (β = - 0.444, z = - 2.223, p < 0.05), and positively associated with HIV-testing intention (β = 0.039, z = 5.121, p < 0.001) and current PrEP use (β = 0.008, z = 2.723, p < 0.01). HIV-related stigma among SMM had a significant and negative indirect effect on HIV-testing intention (β = - 0.017, z = - 2.006, p < 0.05), and current PrEP use (β = - 0.004, z = - 2.009, p < 0.05) through physician-patient interaction quality. Contrary to our expectations, SMM-related stigma did not have a significant and negative indirect effect on HIV prevention behaviors through physician-patient interaction quality. Health interventions need to improve physician-patient interaction quality by offering healthcare provider training, targeting HIV-related stigma in healthcare settings, and devising inclusive healthcare policies to promote HIV prevention efforts.

A gendered analysis of living with HIV/AIDS in the Eastern Region of Ghana

BACKGROUND

A gender gap exists in knowledge regarding persons living with HIV/AIDS in Ghana. Women living with HIV/AIDS (WLHIV) greatly outnumber males living with HIV/AIDS (MLHIV) in Ghana and Sub-Saharan Africa generally. This necessitates more gender-nuanced evidence-based information on HIV/AIDS to guide individuals, healthcare workers, and other stakeholders in Ghana particularly. This paper undertook a gender-focused analysis of the experiences of WLHIV and MLHIV in a municipal area in Ghana which has been most impacted by HIV/AIDS.

METHODS

In-depth interviews of 38 HIV-positive persons recruited using combined purposive and random sampling for one month, were tape recorded and analyzed using thematic content analysis. Participants were out-patients who were receiving routine care for co-morbidities at two specially equipped HIV/AIDS Voluntary Counseling and Testing Centers in the Lower Manya Krobo Municipality (LMKM), Eastern Region, Ghana.

RESULTS

Our data yielded three major themes: characteristics of participants, health status and health seeking behavior, and challenges encountered living with HIV/AIDS. Except for feeling of sadness due to their HIV/AIDS-positive status, there were significant differences in the experiences of MLHIV, compared to WLHIV. WLHIV were more likely to be housing insecure, unemployed due mostly to stigmatization/self-stigmatization, less likely to have revealed their HIV-positive status to multiple family members, and had more profound challenges regarding their healthcare. Most MLHIV expected, demanded, and had support from their wives; WLHIV were mostly single-never married, divorced or widowed (mostly due to HIV/AIDS). The vast majority of WLHIV complained of near-abject poverty, including for most of them, lack of food for taking their anti-retroviral medicines and/or taking it on time.

CONCLUSIONS

The experiences of the MLHIV and WLHIV with living and coping with the virus mostly differed. These experiences were unequivocally shaped by differential socio-cultural tenets and gendered nuances; WLHIV had more negative experiences. Public education on the extra burden of HIV/AIDS on WLHIV, more social support, and affirmative action in policy decisions in favor of WLHIV in the study district are needed to seek public sympathy and improve health outcomes and livelihoods of WLHIV particularly. Further studies using multiple sites to explore these differences are warranted.

Self-Stigma Reduction Interventions for People Living with HIV/AIDS and Their Families: A Systematic Review

Stigma is a primary concern for people living with human immunodeficiency virus (HIV)/AIDS (PLWHA), and has great impact on their and their family members' health. While previous reviews have largely focused on the public stigma, this systematic review aims to evaluate the impact of HIV/acquired immunodeficiency syndrome (AIDS)-related self-stigma reduction interventions among PLWHA and their families. A literature search using eight databases found 23 studies meeting the inclusion criteria. Five types of intervention approaches were identified: (1) psycho-educational intervention, (2) supportive intervention for treatment adherence (antiretroviral therapy), (3) psychotherapy intervention, (4) narrative intervention, and (5) community participation intervention. Overall, the reviewed articles suggested a general trend of promising effectiveness of these interventions for PLWHA and their family members. Psycho-educational interventions were the main approach. The results highlighted the need for more interventions targeting family members of PLWHA, and mixed-methods intervention studies.

Stigma and Discrimination: Threats to Living Positively with Human Immunodeficiency Virus

Antiretroviral therapy and care advances have resulted in people with human immunodeficiency virus (HIV) living longer and enjoying a higher level of physical well-being. Despite such advances, individuals with HIV continue to confront challenges to living positively, including facing the secondary epidemic of stigma and discrimination. Following is a historical overview of the concept of stigma and an exploration of the causes and consequences of multilevel stigma for individuals with HIV. Strategies used by individuals and societies to manage stigma and avoid negative experiences also are examined.

An examination of the psychometric properties and dimensionality of the Aggression-Problem Behavior Frequency Scale in a sample of Black South African adolescents

Advancing research into aggressive behaviour in South Africa necessitates a range of suitable measuring instruments. The Aggression-Problem Behavior Frequency Scale is one such instrument that has been extensively used in diverse settings. The authors of the Aggression-Problem Behavior Frequency Scale present it as a multidimensional scale that purports to measure physical, non-physical, and relational aggression. Despite the widespread use of the scale as a three-factor scale, the psychometric properties, specifically the factor structure of the instrument, have not been examined either globally or in South Africa. This article reports on the reliability, factor structure, and dimensionality of the Aggression-Problem Behavior Frequency Scale among a sample of Black South African adolescents. The scale demonstrated a high level of reliability both in terms of coefficient alpha and coefficient omega. Confirmatory factor analysis indicated that a second-order factor model and a bifactor model demonstrated a better fit than a one-factor model. Despite the superiority of fit of the two models, bifactor indices demonstrated that the Aggression-Problem Behavior Frequency Scale is essentially unidimensional. First, Omega Hierarchical Subscale indicated a significant reduction in the reliability of the subscales after partitioning out the variance attributable to the general factor (total aggression). Second, the percentage of common variance explained by the total scale was 75% with only 25% attributable to the three subscales. While the findings of the study tentatively confirmed the suitability of the Aggression-Problem Behavior Frequency Scale for use in South Africa, the results indicate that there is no empirical basis for the use of subscale scores and that the Aggression-Problem Behavior Frequency Scale is essentially unidimensional.

HIV status disclosure during acute HIV infection in Malawi

Diagnosis of acute HIV infection (AHI) presents an opportunity to prevent HIV transmission during a highly infectious period. Disclosure is important during AHI as a means to facilitate safer sex practices and notify partners, particularly as those with AHI may be better able to identify the source of their infection because of the recency of HIV acquisition. However, little is known about disclosure during AHI. We conducted 40 semi-structured interviews with Malawians diagnosed with AHI (24 men; 21 married). Most participants reported disclosing to a sexual partner within a month of diagnosis, and knew or had a strong suspicion about the source of their infection. Participants often assumed their source had knowingly infected them, contributing to anger and feeling that disclosure is futile if the source already knew their HIV status. Assisted partner notification, individual and couples counseling, and couples HIV testing may facilitate disclosure during AHI.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01450189.

Towards a health-enabling working environment - developing and testing interventions to decrease HIV and TB stigma among healthcare workers in the Free State, South Africa: study protocol for a randomised controlled trial

Background

Occupational exposure to tuberculosis (TB) constitutes a major health risk for healthcare workers (HCWs). The HIV epidemic equally affects the workforce because of the mutually reinforcing epidemiology of HIV and TB. Stigmas associated with HIV and TB have become so intricately entangled that they stop some HCWs from seeking care in a context where serious shortages in human resources for health besiege public health facilities. It is thus imperative to research, as well as attempt to tackle, HIV and TB stigma among HCWs. But little has been done internationally—and nationally, only our own exploratory studies. Our project aims to address this by (1) scientifically assessing the extent and sources of HIV and TB-related stigma among HCWs and (2) developing and testing evidence-based, stigma-reduction interventions in public hospitals in the Free State Province of South Africa.

Methods/design

The research follows a stratified cluster randomised controlled trial (RCT) design. Pre intervention, a self-administered questionnaire with the pilot study’s validated stigma scales is used to measure stigma and other key variables among randomly selected HCWs in eight hospitals—stratified by size and district and then randomly allocated to four intervention and four control sites. Interventions comprise HIV- and TB-stigma reduction activities—mainly Social and Behavioural Change Communication (SBCC) interventions—at three social-ecology levels (individual, community, and socio-structural). An outside assessor will appraise the trial mid-way through implementation. Post intervention, all baseline respondents will be followed up to complete the baseline questionnaire with additional items on interventions. Qualitative data will be collected to better understand HIV and TB stigma and explore if, and how, interventions impact stigma levels in the workplace.

Discussion

The study regards as HCWs all staff, working in all different types of jobs, at all levels in the hospitals. Thus, the research addresses HIV and TB stigma across the whole workforce and the entire workplace. In doing so it will (1) generate essential information on stigma among HCWs and (2) implement stigma-reduction interventions that are innovative yet replicable, and potentially beneficial in addressing a pernicious human-rights-based issue.

Trial registration

South African National Clinical Trials Register, registration ID: DOH-27-1115-5204. Prospectively registered on 26 August 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2713-5) contains supplementary material, which is available to authorized users.

The Development and Piloting of Parallel Scales Measuring External and Internal HIV and Tuberculosis Stigma Among Healthcare Workers in the Free State Province, South Africa

BACKGROUND

The dual burden of tuberculosis and human immunodeficiency virus (HIV) is severely impacting the South African healthcare workforce. However, the use of on-site occupational health services is hampered by stigma among the healthcare workforce. The success of stigma-reduction interventions is difficult to evaluate because of a dearth of appropriate scientific tools to measure stigma in this specific professional setting.

METHODS

The current pilot study aimed to develop and test a range of scales measuring different aspects of stigma-internal and external stigma toward tuberculosis as well as HIV-in a South African healthcare setting. The study employed data of a sample of 200 staff members of a large hospital in Bloemfontein, South Africa.

RESULTS

Confirmatory factor analysis produced 7 scales, displaying internal construct validity: (1) colleagues' external HIV stigma, (2) colleagues' actions against external HIV stigma, (3) respondent's external HIV stigma, (4) respondent's internal HIV stigma, (5) colleagues' external tuberculosis stigma, (6) respondent's external tuberculosis stigma, and (7) respondent's internal tuberculosis stigma. Subsequent analyses (reliability analysis, structural equation modeling) demonstrated that the scales displayed good psychometric properties in terms of reliability and external construct validity.

CONCLUSIONS

The study outcomes support the use of the developed scales as a valid and reliable means to measure levels of tuberculosis- and HIV-related stigma among the healthcare workforce in a resource-limited context. Future studies should build on these findings to fine-tune the instruments and apply them to larger study populations across a range of different resource-limited healthcare settings with high HIV and tuberculosis prevalence.

Prevalence, patterns, and perceived value of complementary and alternative medicine among HIV patients: a descriptive study

BACKGROUND

Use of complementary and alternative medicine (CAM) is widespread among different patient populations despite the availability of evidence-based conventional medicine and lack of supporting evidence for the claims of most CAM types. This study explored the prevalence, patterns, and perceived value of CAM among human immunodeficiency virus (HIV) patients.

METHODS

This quantitative descriptive study was conducted between November 1, 2014 and March 31, 2015 among a cross-sectional, convenience sample of attendees of the HIV clinic of a public tertiary health care institution. Face-to-face interviews using a 34-item questionnaire were conducted. Data analysis included descriptive statistics, chi-square tests, and binary logistic regression analysis.

RESULTS

CAM was used by 113 (32.8%) of a total of 343 HIV patients, but <1% informed their health care providers of CAM usage. Medicinal herbs were the most common type of CAM used (n = 110, 97.3%) followed by spiritual therapy (n = 56, 49.6%), including faith healing/prayer and meditation. The most used medicinal herbs were Aloe vera (n = 54, 49.1%), ginger (n = 33, 30.0%), and garlic (n = 23, 20.9%). The most used vitamins were complex B vitamins (n = 70, 61.9%), followed by vitamin A (n = 58, 51.3%), vitamin E (n = 51, 45.1%), and vitamin D (n = 42, 37.1%). Most CAM users continued using conventional medicine in addition to CAM and were willing to use CAM without supervision and without informing their health care provider. Patients were generally satisfied with CAM therapy (n = 91, 80.5%). The main reasons for CAM use were the desire to take control of their treatment (8.8%) or just trying anything that could help (18.8%). Main influences were the mass media (32.7%) and non-hospital health personnel (19.5%). Predictors of CAM use were being 30-50 years, married and having a secondary school education.

CONCLUSION

About one-third of HIV patients used CAM, but virtually none informed their healthcare provider. Medicinal herbs were the most common type of CAM, followed by spiritual therapy and vitamins. A patient's decision to use CAM was influenced for the most part by the mass media and non- hospital health care personnel.

The multidimensional nature of HIV stigma: evidence from Mozambique

HIV stigma continues to be a major challenge to addressing HIV/AIDS in various countries in sub-Saharan Africa, including Mozambique. This paper explores the multidimensional nature of HIV stigma through the thematic analysis of five qualitative studies conducted in high HIV prevalence provinces in Mozambique between 2009 and 2012. These studies included 23 interviews with people living with HIV (PLHIV) (10 women and 13 men); 6 focus groups with 32 peer educators (24 women and 8 men) working for community-based organisations (CBOs) providing services to PLHIV; 17 focus groups with community members (72 men and 70 women); 6 interviews (4 women and 2 men) with people who had family members living with HIV/AIDS; 24 focus groups (12 with men and 12 with women) and 6 interviews with couples. Our findings indicate that HIV stigma is a barrier to HIV testing and counselling, status disclosure, partner notification, and antiretroviral therapy (ART) access and adherence, and that moral stigma seems to be more common than physical stigma. Additionally, the findings highlight that HIV stigma is a dynamic social process that is conceptualised as being tied to personal responsibility. To effectively diminish HIV stigma in Mozambique, future interventions should address moral stigma and re-conceptualise HIV as a chronic disease.

Another Generation of Stigma? Assessing Healthcare Student Perceptions of HIV-Positive Patients in Mwanza, Tanzania

HIV-related stigma remains a persistent global health concern among people living with HIV/AIDS (PLWA) in developing nations. The literature is lacking in studies about healthcare students' perceptions of PLWA. This study is the first effort to understand stigmatizing attitudes toward HIV-positive patients by healthcare students in Mwanza, Tanzania, not just those who will be directly treating patients but also those who will be indirectly involved through nonclinical roles, such as handling patient specimens and private health information. A total of 208 students were drawn from Clinical Medicine, Laboratory Sciences, Health Records and Information Management, and Community Health classes at the Tandabui Institute of Health Sciences and Technology for a voluntary survey that assessed stigmatizing beliefs toward PLWA. Students generally obtained high scores on the overall survey instrument, pointing to low stigmatizing beliefs toward PLWA and an overall willingness to treat PLWA with the same standard of care as other patients. However, there are gaps in knowledge that exist among students, such as a comprehensive understanding of all routes of HIV infection. The study also suggests that students who interact with patients as part of their training are less likely to exhibit stigmatizing beliefs toward PLWA. A comprehensive course in HIV infection, one that includes classroom sessions focused on the epidemiology and routes of transmission as well as clinical opportunities to directly interact with PLWA-perhaps through teaching sessions led by PLWA-may allow for significant reductions in stigma toward such patients and improve clinical outcomes for PLWA around the world.

Risk factors for postpartum depression in women living with HIV attending prevention of mother-to-child transmission clinic at Kenyatta National Hospital, Nairobi

Mothers with HIV are at high risk of a range of psychosocial issues that may impact HIV disease progression for themselves and their children. Stigma has also become a substantial barrier to accessing HIV/AIDS care and prevention services. The study objective was to determine the prevalence and severity of postpartum depression (PPD) among women living with HIV and to further understand the impact of stigma and other psychosocial factors in 123 women living with HIV attending prevention of mother-to-child transmission (PMTCT) clinic at Kenyatta National Hospital located in Nairobi, Kenya. We used the Edinburgh Postnatal Depression Scale and HIV/AIDS Stigma Instrument - PLWHA (HASI - P). Forty-eight percent (N = 59) of women screened positive for elevated depressive symptoms. Eleven (9%) of the participants reported high levels of stigma. Multivariate analyses showed that lower education (OR = 0.14, 95% CI [0.04-0.46], p = .001) and lack of family support (OR = 2.49, 95% CI [1.14-5.42], p = .02) were associated with the presence of elevated depressive symptoms. The presence of stigma implied more than ninefold risk of development of PPD (OR = 9.44, 95% CI [1.132-78.79], p = .04). Stigma was positively correlated with an increase in PPD. PMTCT is an ideal context to reach out to women to address mental health problems especially depression screening and offering psychosocial treatments bolstering quality of life of the mother-baby dyad.

HIV-related stigma: implications for symptoms of anxiety and depression among Malawian women

An estimated 11% of the adult population in Malawi, Africa, is living with HIV/AIDS. The disease has taken a toll on communities, resulting in high morbidity and mortality. Malawian women carry the burden of being caretakers for individuals infected with HIV while also worrying about their own health. However, little is known about how HIV/ AIDS affects psychological functioning among Malawian women in areas hit hardest by the epidemic. To that end, this paper examined the influence of HIV-related stigma on symptoms of anxiety and depression among 59 women 17-46 years old who were recruited from the Namitete area of Malawi. Women who reported greater worry about being infected with HIV and greater HIV-related stigma were significantly more likely to report greater symptoms of anxiety and depression. These findings suggest that interventions that reduce HIV-related stigma are likely to enhance psychological functioning among Malawian women, which in turn will improve the women's quality of life and well-being.

Knowledge and Attitudes toward HIV, Hepatitis B Virus, and Hepatitis C Virus Infection among Health-care Workers in Malawi

Objective:

The highest prevalence of HIV infection occurs in Sub-Saharan Africa and hepatitis B virus (HBV), and hepatitis C virus (HCV) prevalence are the second highest in Sub-Saharan Africa including Malawi. Health-care workers (HCWs) play an important role in the prevention of, response to, and management of these infectious diseases. There is, however, no published research about the level of knowledge and attitudes toward HIV, HBV, and HCV infection among Malawian HCWs. The purpose of this study was to explore and determine the knowledge of and attitudes toward HIV, HBV, and HCV among a targeted population of Malawian HCWs.

Methods:

A cross-sectional community-based participatory research with 194 HCWs was completed employing health survey method. The project was a collaborative effort between nursing faculties in the USA and Malawian. A one-way analysis of variance (ANOVA) with the Bonferroni adjustment for multiple comparisons was used to assess the differences in knowledge and attitude among three subgroups of HCWs.

Results:

Of 194 of Malawian HCWs surveyed, 41% were support staff, 37% were nursing students, and 22% were health-care professionals. Both health-care professionals and support staff had high knowledge scores related to HIV/AIDS, and their attitudes were mainly positive. However, a series of one-way ANOVAs revealed significant differences in knowledge and attitude toward HIV/AIDs, HBV, and HCV among HCWs (P < 0.01). The majority had less knowledge about HBV and HCV and more negative attitudes toward hepatitis.

Conclusions:

This study highlights the ongoing need for reducing negative attitudes toward HIV, HBV, and HCV; and providing health education among HCWs, especially focusing on HBV and HCV prevention. The findings of the research project can be used to develop interventions addressing low HBV- and HCV-related knowledge and attitudes.

"Doing the Best We Can": Providing Care in a Malawian Antiretroviral Clinic

Following a national policy shift toward universal access to antiretroviral therapy (ART) in Malawi, hospitals and clinics around the country made major changes to enable the provision of ART. In this already resource-limited environment, the provision of ART brought new health care delivery challenges to bear on both patients and health care professionals. The substance and form of these local interventions are affected by a multilayered global context. Drawing on fieldwork in an antiretroviral clinic in rural Malawi, this article discusses the daily implications of providing and receiving care in the context of a massive global shift in health policy, and argues that in order to fully understand the process of service rollout in all its complexity, care should be explored not only from the patients' perspective but also from that of local and international health care professionals and policymakers.

TB/HIV-related training, knowledge and attitudes of community health workers in the Free State province, South Africa

With its emphasis on task shifting and multi-trained and skilled outreach teams the primary healthcare (PHC) re-engineering strategy in South Africa depends on the training, knowledge and attitudes of community health workers (CHWs) to provide a variety of TB/HIV services. The aim of this exploratory research was to assess TB/ HIV-related training, knowledge and attitudes of CHWs. Interviews were conducted with 206 CHWs at 28 clinics in 1 urban and 2 rural sub-districts in the Free State province. Descriptive and bivariate analyses were performed using chi-square, Kruskal-Wallis (H) and Mann-Whitney (U) tests for non-parametric data. More than half (54.9%) had not received basic training in HIV counselling and testing; almost one-third (31.1%) had not received basic training in TB/directly observed treatment (DOT) support. Furthermore, most CHWs had not received any follow-up training in HIV counselling and testing and in TB/DOT support. Significant associations (0.01 < p < 0.05) between the types of CHWs and their sub-district location, and their TB/HIV-related training, knowledge and attitudes were observed. In respect of the TB/HIV knowledge items assessed, a large majority (>95%) were knowledgeable, with only a few being ignorant about important facts related to TB/HIV. Lay counsellors were significantly more knowledgeable about TB/HIV than TB/DOT supporters and other CHWs were. Most CHWs disagreed with stigmatising statements about people with TB/HIV. The sub-district location of CHWs was significantly associated with their attitudes towards people with TB/HIV. CHWs in the two rural sub-districts were more likely to agree with stigmatising statements. In the context of PHC re-engineering, this exploratory research suggests that CHW TB/HIV training, knowledge and attitudes can and need to be improved if integrated TB/HIV services are to be successfully task-shifted to them in line with policy recommendations.

The impact of water, sanitation, and hygiene interventions on the health and well-being of people living with HIV: a systematic review

BACKGROUND

Access to improved water supply and sanitation is poor in low-income and middle-income countries. Persons living with HIV/AIDS (PLHIV) experience more severe diarrhea, hospitalizations, and deaths from diarrhea because of waterborne pathogens than immunocompetent populations, even when on antiretroviral therapy (ART).

METHODS

We examined the existing literature on the impact of water, sanitation, and hygiene (WASH) interventions on PLHIV for these outcomes: (1) mortality, (2) morbidity, (3) retention in HIV care, (4) quality of life, and (5) prevention of ongoing HIV transmission. Cost-effectiveness was also assessed. Relevant abstracts and articles were gathered, reviewed, and prioritized by thematic outcomes of interest. Articles meeting inclusion criteria were summarized in a grid for comparison.

RESULTS

We reviewed 3355 citations, evaluated 132 abstracts, and read 33 articles. The majority of the 16 included articles focused on morbidity, with less emphasis on mortality. Contaminated water, lack of sanitation, and poor hygienic practices in homes of PLHIV increase the risk of diarrhea, which can result in increased viral load, decreased CD4 counts, and reduced absorption of nutrients and antiretroviral medication. We found WASH programming, particularly water supply, household water treatment, and hygiene interventions, reduced morbidity. Data were inconclusive on mortality. Research gaps remain in retention in care, quality of life, and prevention of ongoing HIV transmission. Compared with the standard threshold of 3 times GDP per capita, WASH interventions were cost-effective, particularly when incorporated into complementary programs.

CONCLUSIONS

Although research is required to address behavioral aspects, evidence supports that WASH programming is beneficial for PLHIV.

A qualitative study of patient motivation to adhere to combination antiretroviral therapy in South Africa

Taken as prescribed, that is, with high adherence, combination antiretroviral therapy (ART) has changed HIV infection and disease from being a sure predictor of death to a manageable chronic illness. Adherence, however, is difficult to achieve and maintain. The CAPRISA 058 study was conducted between 2007 and 2009 to test the efficacy of individualized motivational counselling to enhance ART adherence in South Africa. As part of the overall trial, a qualitative sub-study was conducted, including 30 individual interviews and four focus group discussions with patients in the first 9 months of ART initiation. Data were inductively analyzed, using thematic analysis, to identify themes central to ART adherence in this context. Four themes emerged that characterize the participants' experiences and high motivation to adhere to ART. Participants in this study were highly motivated to adhere, as they acknowledged that ART was 'life-giving', in the face of a large amount of morbidity and mortality. They were further supported by techniques of routine remembering, and highlighted the importance of good social support and access to supportive healthcare workers, to their continued success in negotiating their treatment. Participants in the current study told us that their adherence motivation is enhanced by free accessible care, approachable and supportive healthcare workers, broad social acceptance of ART, and past first-hand experiences with AIDS-related co-morbidity and mortality. Programs that include specific attention to these aspects of care will likely be successful in the long term.

A model for understanding the relationship between stigma and healthcare-seeking behaviour among people living with HIV/AIDS in sub-Saharan Africa

People living with HIV or AIDS (PLHIV) in sub-Saharan Africa sometimes have care-seeking behaviours that result in a suboptimal quality of life. This paper seeks to examine the role of stigma in the care-seeking behaviour of PLHIV. We hypothesise that stigma relates to the behaviour of PLHIV themselves and with societal reactions, including those of healthcare professionals. From a literature review, we identified the following as important correlates of care-seeking behavior: beliefs about pathways of HIV infection and people infected with HIV, social reactions, coping strategies, knowledge of HIV and AIDS, and self-efficacy in finding care and treatment in addition to coping with the disease. Poverty, gender, age, religion and policy were found to be moderating variables. The Precede-Proceed model was adapted to build an explanatory model of healthcare-seeking behaviour among PLHIV and particularly to explore the role of stigma in the non-utilisation of healthcare institutions.

Suitability of quality-of-life outcome measures in palliative care in the South African setting

OBJECTIVE

Quality of life (QoL) is a multidimensional, subjective, and highly individual phenomenon. The current study speaks to the QoL domains identified by palliative patients living in Africa. The need to identify these domains has been recognized but seemed to still be lacking. This study filled this knowledge gap by providing the domains and by giving directions in terms of the assessment of QoL in palliative patients living in resource-restricted communities in South Africa.

METHOD

We followed a multi-method approach and conducted a literature review to identify and describe the multidimensional QoL instruments used in African palliative care. A secondary analysis design and open-coding method was employed to identify the domains influencing the QoL of palliative patients living in a resource-restricted South African community, after which we compared these domains to the domains assessed by the identified QoL instruments.

RESULTS

We found that two multidimensional QoL of life instruments-the Missoula-Vitas Quality of Life Index (MVQoLI) and the Functional Assessments of Chronic Illness Therapy-Palliative Care (FACIT-Pal)-have been used in African palliative care and have identified various domains, grouped as four themes: physical concerns, psychosocial issues, financial restraints, and existential issues. The patient-identified QoL domains were to a great extent not assessed by the MVQoLI and FACIT-Pal.

SIGNIFICANCE OF RESULTS

Our study highlights the complexity of QoL and QoL assessment. A more accurate representation of the QoL of palliative patients living in resource-restricted communities might be obtained by using individualized measures or exploring what QoL means to these patients and selecting QoL instruments accordingly.

An exploratory survey measuring stigma and discrimination experienced by people living with HIV/AIDS in South Africa: the People Living with HIV Stigma Index

Background

The continued presence of stigma and its persistence even in areas where HIV prevalence is high makes it an extraordinarily important, yet difficult, issue to eradicate. The study aimed to assess current and emerging HIV/AIDS stigma and discrimination trends in South Africa as experienced by people living with HIV/AIDS (PLHIV).

Methods

The PLHIV Stigma Index, a questionnaire that measures and detects changing trends in relation to stigma and discrimination experienced by PLHIV, was used as the survey tool. The study was conducted in 10 clinics in four provinces supported by the Foundation for Professional Development (FPD), with an interview total of 486 PLHIV. A cross-sectional design was implemented in the study, and both descriptive and inferential analysis was conducted on the data.

Results

Findings suggest that PLHIV in this population experience significant levels of stigma and discrimination that negatively impact on their health, working and family life, as well as their access to health services. Internalised stigma was prominent, with many participants blaming themselves for their status.

Conclusion

The findings can be used to develop and inform programmes and interventions to reduce stigma experienced by PLHIV. The current measures for dealing with stigma should be expanded to incorporate the issues related to health, education and discrimination experienced in the workplace, that were highlighted by the study.

Correlates of social exclusion and negative labeling and devaluation of people living with HIV/AIDS in rural settings: evidence from a General Household Survey in Zambézia Province, Mozambique

Background

Increased HIV/AIDS knowledge and access to antiretroviral treatment (ART) have been hypothesized to decrease HIV stigma. However, stigma persists as a barrier to HIV services uptake. We studied the relationship between stigma, knowledge and attitudes towards HIV and its treatment, and confidence in the legal system (legal rights certitude).

Methods

We analyzed data from a household survey of 3749 randomly sampled female heads of households in 259 enumeration areas across 14 districts of Zambézia Province, Mozambique. The questionnaire included questions about beliefs, attitudes and behavior towards PLWHA, HIV transmission knowledge, treatment-related beliefs, and legal rights certitude. Factor analysis distinguished two stigma constructs: Negative labeling and devaluation (NLD) and social exclusion (SoE). Multivariable linear regression was used to determine the association between stigma, knowledge of HIV/AIDS, treatment-related beliefs, and legal rights certitude, while controlling for variance in socio-demographics.

Results

A 4-point increase in knowledge about HIV transmission was associated with more than a 3 unit decrease in NLD and SoE stigma scores (p<0.001). Given HIV transmission knowledge, a 25-point increase in legal rights certitude was associated with a 4.62 unit drop in NLD stigma (p<0.001); we did not detect an association between legal rights certitude and SoE stigma. Knowing at least one HIV positive person was associated with lower SoE (−3.17, 95% CI: −5.78, −0.56); no association with NLD (p = 0.1) was detected. ART efficacy belief was associated with higher NLD and lower SoE (2.90 increase and 6.94 decrease, respectively; p≤0.001).

Conclusion

Increasing knowledge about HIV transmission and access to ART are likely to reduce stigma, but neither of the two is a panacea. Raising community awareness of the legal rights of PLWHA might improve the efficacy of stigma reduction efforts. Strategies that focus on specific domains of stigma might be more effective than generic stigma reduction strategies.

'My dreams are shuttered down and it hurts lots'-a qualitative study of palliative care needs and their management by HIV outpatient services in Kenya and Uganda

BACKGROUND

Despite the huge burden of HIV in sub-Saharan Africa, there is little evidence of the multidimensional needs of patients with HIV infection to inform the person-centred care across physical, psychological, social and spiritual domains stipulated in policy guidance. We aimed to describe the problems experienced by people with HIV in Kenya and Uganda and the management of these problems by HIV outpatient services.

METHODS

Local researchers conducted in depth qualitative interviews with HIV patients, caregivers and service staff at 12 HIV outpatient facilities (6 in Kenya, 6 in Uganda). Interview data were analysed thematically.

RESULTS

189 people were interviewed (83 patients, 47 caregivers, 59 staff). The impact of pain and symptoms and their causes (HIV, comorbidities, treatment side-effects) were described. Staff reported that effective pain relief was not always available, particularly in Kenya. Psychosocial distress (isolation, loneliness, worry) was exacerbated by stigma and poverty, and detrimentally affected adherence. Illness led to despair and hopelessness. Provision of counselling was reported, but spiritual support appeared to be less common. Neither pain nor psychosocial problems were routinely reported to service staff. Collaboration with local hospices and income-generation activities for patients were highlighted as useful.

CONCLUSIONS

The findings demonstrate the multiple and interrelated problems associated with living with HIV and how psychosocial and spiritual distress can contribute to 'total pain' in this population. In line with the palliative care approach, HIV care requires holistic care and assessment that take into account psychological, socioeconomic and spiritual distress alongside improved access to pain-relieving drugs, including opioids.

HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: a review of the evidence

The global community has set goals of virtual elimination of new child HIV infections and 50 percent reduction in HIV-related maternal mortality by the year 2015. Although much progress has been made in expanding prevention of mother-to-child transmission (PMTCT) services, there are serious challenges to these global goals, given low rates of utilization of PMTCT services in many settings. We reviewed the literature from low-income settings to examine how HIV-related stigma affects utilization of the series of steps that women must complete for successful PMTCT. We found that stigma negatively impacts service uptake and adherence at each step of this "PMTCT cascade". Modeling exercises indicate that these effects are cumulative and therefore significantly affect rates of infant HIV infection. Alongside making clinical services more available, effective, and accessible for pregnant women, there is also a need to integrate stigma-reduction components into PMTCT, maternal, neonatal, and child health services.

Stigma, medication adherence and coping mechanism among people living with HIV attending General Hospital, Lagos Island, Nigeria

Background

People living with HIV and AIDS (PLWHA) experience some form of stigma which could lead to poor medication adherence.

Objectives

This study assessed the various domains of stigma experienced by PLWHAs attending an HIV clinic at General Hospital, Lagos Island, their medication adherence patterns and their coping mechanisms for ensuring adherence to antiretroviral therapy.

Method

A cross-sectional study design with a sample size of 200 was used. Respondents were selected using systematic random sampling. Interviewers administered structured questionnaires were used to collect information on the domains of stigma. Data was analysed using EPI info^©. This was followed by a focus group discussion (FGD) with seven participants at the clinic using an interview guide with open-ended questions.

Results

Overall, stigma was experienced by 35% of the respondents. Within this group, 6.6%, 37.1%, 43.1% and 98.0% of the respondents reported experiencing negative self image stigma, personalised stigma, disclosure stigma and public attitude stigma respectively. Almost 90% of the respondents were adherent. The FGD revealed that disclosure was usually confined to family members and the coping mechanism for achieving adherence was to put antiretroviral (ARVs) in unlabelled pill boxes.

Conclusion

This study found that stigma was low and that the most common domain of stigma experienced was public attitude stigma. Medication adherence of respondents was good as a result of the coping mechanism, which involves putting ARVs in unlabelled pill boxes.

Factors associated with pregnant women's anticipations and experiences of HIV-related stigma in rural Kenya

Pregnant women who fear or experience HIV-related stigma may not get care for their own health or medications to reduce perinatal transmission of HIV. This study examined factors associated with anticipating and experiencing HIV-related stigma among 1777 pregnant women attending antenatal care clinics in rural Kenya. Women were interviewed at baseline, offered HIV testing and care, and a sub-set was re-interviewed at 4-8 weeks postpartum. Women who were older, had less education, whose husbands had other wives, and who perceived community discrimination against people with HIV had significantly greater adjusted odds of anticipating HIV stigma. Over half of the HIV-positive women interviewed postpartum reported having experienced stigma, much of which was self-stigma. Women experiencing minor depression, and those whose family knew of their HIV status had significantly greater adjusted odds of experiencing stigma. Lack of women's empowerment, as well as depression, may be important risk factors for HIV-related stigma and discrimination.

Knowledge, attitudes and behaviours of health care workers towards clients of sexual health services in Fiji

A cross-sectional survey was conducted to identify the attitudes and behaviours of health care workers (HCWs) in health care settings (HCS) in Fiji involving 369 participants. Self-rated knowledge of HIV and sexually transmissible infections (STIs) varied depending on whether the HCS was divisional or sub-divisional, and varied between the various national divisions. HCWs with experience in HIV, reproductive health and antenatal clinics had higher self-rated HIV knowledge. A high proportion had a fear of catching HIV from HIV-positive clients. This study found high levels of negative attitudes towards clients from vulnerable groups with regards to the transmission and spread of HIV. Study participants also reported observing differential treatment by their colleagues if a client was known to have or was suspected of having HIV. There is a need for further HIV education of HCWs, with training focussed on occupational risk, and on reducing stigma and discrimination of those living with or vulnerable to HIV in Fiji.

Masculinity and HIV disclosure among heterosexual South African men: implications for HIV/AIDS intervention

Relationships and constructions of masculinity are central to understanding the process of male HIV disclosure, which is an important step towards accessing HIV-related services. Data from in-depth interviews and focus-group discussions with 23 HIV-positive, self-identified heterosexual, Black South African men were used to explore the disclosure process and how this process was negotiated in the context of constructions of masculinity. Of these men, 20 had disclosed to one or more persons, with partners and siblings being the preferred confidants. Disclosure was dependent on the acceptance of HIV status, perceived support and healthy relationships with others, HIV counselling and participation in educational and training activities. Non-disclosure was explained as a result of stigma, fear of rejection, discrimination, a lack of healthy relationships with others and lack of access to suitable disclosure strategies. Negative perceptions of HIV and hegemonic conceptions of masculinity hindered men from disclosing and seeking health services. Many men, however, managed to renegotiate their masculine identities to become responsible, knowledgeable HIV-positive individuals, protecting their families and becoming community educators. Findings suggest the need to consider gendered, contextual, skills-building/income-generating and guided interventions to promote male HIV disclosure and service uptake.

Free love: a case study of church-run home-based caregivers in a high vulnerability setting

The purpose of this study is to explore the concept of religious health assets (RHA) and its relevance to HIV/AIDS. This manuscript describes the experiences of caregivers with a church-run home-based care organisation in Swaziland, site of the world's highest HIV prevalence (42%). In light of reduced antiretroviral treatment rollout in some areas of Africa, strengthening mechanisms of treatment support with HIV prevention has never been more critical. One modality may be community home-based care (CHBC), a core feature of the World Bank's Multi-Country HIV/AIDS Program for Africa. Yet, these entities, and the frontline activities of local congregations, remain underexplored. Part of a larger anthropological study of religion and HIV/AIDS in Swaziland, this manuscript draws on 20 semi-structured caregiver interviews to discern patterns in motivations; perceived client needs; care practices; and meanings of religiosity. Thirteen participants were care coordinators who oversaw approximately 455 caregivers across nearly half of the 22 communities served. Grounded theory analysis suggested that caregivers facilitated vital decisions around HIV testing, HIV disclosure, treatment uptake/adherence, as well as reduced HIV stigma. Also salient was the importance of a Christian ethos, in the form of 'talk' and 'love', as critical culturally situated care practices. Having expanded to an estimated 600 caregivers and 2500 home-based clients between 2006 and 2009, Participants' reports intimated their roles as agents of broader social transformation. This article contributes to the expanding study of RHA and challenges authoritative global public health strategies that have largely marginalised local religious aspects of HIV/AIDS. Future applied research examining how 'home' and 'church' may be vital public health settings outside of, but integral to, formal health services and HIV programming is warranted.

Stigma, burden, social support, and willingness to care among caregivers of PLWHA in home-based care in South Africa

Despite its benefits for people living with HIV/AIDS (PLWHA), home-based care (HBC) may have negative effects on caregivers. Caregivers experience high levels of burden and may be targets of HIV-related prejudice and discrimination. In this cross-sectional survey of 358 caregivers from five hospices across KwaZulu-Natal, South Africa, 49 (13.7%) caregivers personally experienced discrimination as a result of caring for PLWHA. One hundred and seventy (47.5%) marked one or more items on the HIV stigma scale. Eighty-eight percent had low to moderate levels of caregiver burden. People with higher level of burden and higher income were more likely to hold stigmatizing beliefs. Caregivers with the following characteristics: support from a nurse, support from community careworker, HIV stigmatizing beliefs, and personal experience of discrimination as result of caring for PLWHA and low caregiver burden, had more than twice the odds of wanting to care for another PLWA in the future. Overall, caregivers in HBC experience low level of severe caregiver burden. The support offered to caregivers from the hospice and relatively low levels of discrimination encourage expansion of HBC programs for PLWHA.

The acceptance and feasibility of replacement feeding at 6 months as an HIV prevention method in Lilongwe, Malawi: results from the BAN study

International guidelines recommend EBF to age 6 months among HIV-infected mothers choosing to breast-feed and cessation thereafter if replacement feeding is acceptable, feasible, affordable, sustainable, and safe. When mothers wean, they are challenged to provide an adequate replacement diet. This study investigates the use and acceptability of a lipid-based nutrient supplement (LNS) as a breast-milk substitute when provided to infants (6-12 mo) of HIV-positive mothers, as part of the Breast-feeding, Antiretroviral, and Nutrition (BAN) Study. A sub-sample of mothers (n = 45) participated in interviews that explored EBF, weaning, and strategies to feed LNS. Mothers reported several weaning strategies, including gradual reduction of breast-feeding, expressing breast-milk into a cup, and separation of mother and child. LNS, a peanut-based micronutrient fortified paste, was highly accepted and incorporated into the traditional diet. Weaning is a feasible HIV prevention method among this population in Malawi when supported by the provision of LNS as a breast-milk substitute.

Where will this illness take me? Reactions to HIV diagnosis from women living with HIV in Kenya

The purpose of our study was to develop an in-depth understanding of the reactions of 40 urban and rural HIV-infected Kenyan women to HIV diagnosis. We employed narrative inquiry principles to guide this qualitative cross-sectional study. We conducted individual in-depth interviews using open-ended questions in April and May 2006. In this article we focus on women's reactions to HIV diagnosis, under which four subthemes emerged: immediate intense emotions; keeping HIV status secret; acceptance of HIV diagnosis; and finding liberation in disclosure. We offer important implications for health care professionals serving women in sub-Saharan Africa from the findings of our study.

Assessment of Stigma and Discrimination Experienced by People Living with HIV and AIDS Receiving Care/Treatment in University of Ilorin Teaching Hospital (UITH), Ilorin, Nigeria

The research was designed to assess the stigma and discrimination faced by People living with HIV and AIDS (PLWHA) that are receiving treatment in UITH, Ilorin. The study was a descriptive cross-sectional survey conducted on three hundred (300) people living with HIV and AIDS receiving care at the antiretroviral therapy (ART) clinics within University of Ilorin Teaching Hospital (which was the only ART site in Kwara State as at then). A quantitative method through the use of interviewer administered questionnaire was used for data collection. This study was a cross-sectional descriptive study design. All the patients who came to the clinic and met the selection criteria were recruited until the desired sample size was reached. Data were analyzed by EPI-INFO 2005 software package. The mean age of the respondents was 39 years (SD = 9.32), and their age ranged between 19 and 65 years. About two thirds (64.7%) of the respondents were females, 62.7% were married, and 62.9% were from monogamous family settings. Slightly less than half (47.3%) of the respondents were not informed before they were tested for HIV, majority (63.3%) were not counseled before the test, but only 11% did not receive posttest counseling. One quarter of the respondents had experienced stigmatization/discrimination. Various forms of stigmatization/discrimination experienced by the respondents include blame for being responsible for their HIV status, various name callings, telling them that they are no more useful to anybody, violation of confidentiality, social isolation, restriction of their participation in family/religious activities, rejection by their spouses/families, dismissal from place of work, isolating them from other patients, and denying them care at health centers. It is therefore recommended that government at all levels should develop and implement programs to educate health care providers about HIV and AIDS, ethics, and treatment and care; educate the general population on HIV and AIDS, put in place policies that will reduce/stop HIV-related stigma and discrimination at all levels of the society, educate PLWHA on their right to live and work without discrimination, and also ensure full community participation in HIV control programs.

HIV/AIDS stigma at the workplace: exploratory findings from Pakistan

People living with HIV/AIDS (PLHA) are stigmatised socially. They are devalued and considered like outcasts by having lesser opportunities for education, treatment and housing, and in an organisational context they get reduced opportunities of selection, promotion and income. The phenomena have been extensively researched in developed countries but limited literature addresses the situation in underdeveloped countries like Pakistan, which is also facing spread of the HIV/AIDS epidemic. There are a number of groups who are carrying the disease but the problems being faced by PLHA employed in different organisations have rarely been analysed. Stigma at the workplace can generate a number of negative outcomes. The present study considers two such outcomes among stigmatised PLHA. These outcomes are organisational cynicism and breach of psychological contract. A questionnaire was used to collect data from a sample of 174 PLHA, having a work experience after identification of the epidemic, working in different organisations across Pakistan. These PLHA were identified and recruited through a scattered record available with some government/non-government organisations operating in Pakistan to control HIV/AIDS. Findings of the study extend the knowledge about HIV/AIDS stigma indicating that PLHA are subjected to stigma, which is significantly associated with a breach of psychological contract and organisational cynicism. There is a need at governmental and organisational level as well to increase awareness about the disease and formulate policies to reduce stigma against PLHA working in different organisations.

Situating experiences of HIV-related stigma in Swaziland

With the world's highest antenatal HIV prevalence rate (39.2%), Swaziland has also been described as among the most stigmatising. Yet, only recently was an anti-HIV stigma and discrimination (S&D) platform included in the government's National Multisectoral HIV and AIDS Policy. This study draws on a medical anthropological project in rural Swaziland to examine experiences of stigma among people living with HIV/AIDS (PLWH). Qualitative methods included a semi-structured questionnaire and interviews (n=40) to identify patterns of stigma across three domains: verbal, physical and social. Key informant interviews (n=5) were conducted with health personnel and support group leaders. Descriptive statistics were situated within a thematic analysis of open-ended content. Among the findings, participants reported extensive HIV-related rumouring (36.4%) and pejorative name-calling (37.5%). Nearly one in five (18.2%) could no longer partake of family meals. Homesteads, which are an organising principle of Swazi life, were often markedly stigmatising environments. In contrast to documented discrimination in health care settings, the health centre emerged as a space where PLWH could share information and support. Given the UNAIDS call for national partners to 'know your epidemic' by tracking the prevalence of HIV-related S&D, results from this study suggested that unless 'knowing your epidemic' includes the lived experiences of HIV stigma that blister into discernible patterns, effectiveness of national initiatives is likely to be limited. Multidisciplinary and locale-specific studies are especially well suited in examining the cultural dynamics of HIV stigma and in providing grounded data that deepen the impact of comprehensive HIV/AIDS policies and programming.

Health perceptions of African HIV-infected patients and their physicians

OBJECTIVE

We explored how patients from Sub Saharan Africa (SSA) infected with HIV and living in Switzerland, and their treating physicians perceived their health, whether these perceptions correlated with biological markers, and what organisational changes participants considered likely to improve quality of care.

METHODS

A prospective standardized questionnaire was submitted to HIV-infected patients from SSA and their physicians. Results were correlated with biological data.

RESULTS

While physicians deduced improved health status from laboratory results, these did not provide an adequate surrogate marker of good health for patients. Patients experienced important social and economical difficulties with adverse consequences on their mental health. They requested social assistance, whereas physicians sought improved cultural competency.

CONCLUSION

Patients and physicians did not agree in their evaluation of patients' health status. Patients did not perceive their health through biological markers, but linked their mental health with their socioeconomic context. Physicians underestimated patients' biological health and their evaluation of global health.

PRACTICE IMPLICATIONS

Exploring difficulties perceived by physicians with specific patients lead to identification of structural weaknesses, resulting in suggestions to improve physicians' medical training and patients' care. This illustrates the importance of accessing patients' perspective and not relying solely on physicians' perception of the problem.

Prejudice and misconceptions about tuberculosis and HIV in rural and urban communities in Ethiopia: a challenge for the TB/HIV control program

Background

In Ethiopia, where HIV and tuberculosis (TB) are very common, little is known about the prejudice and misconceptions of rural communities towards People living with HIV/AIDS (PLHA) and TB.

Methods

We conducted a cross sectional study in Gilgel Gibe Field Research area (GGFRA) in southwest Ethiopia to assess the prejudice and misconceptions of rural and urban communities towards PLHA and TB. The study population consisted of 862 randomly selected adults in GGFRA. Data were collected by trained personnel using a pretested structured questionnaire. To triangulate the findings, 8 focus group discussions among women and men were done.

Results

Of the 862 selected study participants, 750(87%) accepted to be interviewed. The mean age of the respondents was 31.2 (SD ± 11.0). Of the total interviewed individuals, 58% of them were females. More than half of the respondents did not know the possibility of transmission of HIV from a mother to a child or by breast feeding. For fear of contagion of HIV, most people do not want to eat, drink, and share utensils or clothes with a person living with HIV/AIDS. A higher proportion of females [OR = 1.5, (95% CI: 1.0, 2.2)], non-literate individuals [OR = 2.3, (95%CI: 1.4, 3.6)], rural residents [OR = 3.8, (95%CI: 2.2, 6.6)], and individuals who had poor knowledge of HIV/AIDS [OR = 2.8, (95%CI: 1.8, 2.2)] were more likely to have high prejudice towards PLHA than respectively males, literates, urban residents and individuals with good knowledge. Exposure to cold air was implicated as a major cause of TB. Literates had a much better knowledge about the cause and methods of transmission and prevention of TB than non-literates. More than half of the individuals (56%) had high prejudice towards a patient with TB. A larger proportion of females [OR = 1.3, (95% CI: 1.0, 1.9)] and non-literate individuals [OR = 1.4, (95% CI: 1.1, 2.0)] had high prejudice towards patients with TB than males and literate individuals.

Conclusion

TB/HIV control programs in collaboration with other partners should invest more in social mobilization and education of the communities to rectify the widespread prejudice and misconceptions.

Understanding and responding to HIV/AIDS stigma and disclosure: an international challenge for mental health nurses

Stigma and discrimination are challenges in the care and treatment of persons with HIV infection worldwide. Fear of negative social consequences often causes persons with HIV/AIDS to keep their infection secret, resulting in negative psychological and physical outcomes and continued spread of the disease. Mental health nurses have a unique opportunity to influence the trajectory of HIV/AIDS though counseling and interventions that address HIV/AIDS stigma with clients, communities, and society. This article provides an in-depth examination of HIV/AIDS stigma and its relationship to nondisclosure as well as strategies to deal with these issues at individual and group levels.

The impact of taking or not taking ARVs on HIV stigma as reported by persons living with HIV infection in five African countries

AIM

This study examined the impact of taking or not taking antiretroviral (ARV) medications on stigma, as reported by people living with HIV infection in five African countries.

DESIGN

A two group (taking or not taking ARVs) by three (time) repeated measures analysis of variance examined change in reported stigma in a cohort sample of 1454 persons living with HIV infection in Lesotho, Malawi, South Africa, Swaziland, and Tanzania. Participants self-reported taking ARV medications and completed a standardized stigma scale validated in the African context. Data were collected at three points in time, from January 2006 to March 2007. Participants taking ARV medications self-reported a mean CD4 count of 273 and those not taking ARVs self-reported a mean CD4 count of 418.

RESULTS

Both groups reported significant decreases in total HIV stigma over time; however, people taking ARVs reported significantly higher stigma at Time 3 compared to those not taking ARVs.

DISCUSSION

This study documents that this sample of 1454 HIV infected persons in five countries in Africa reported significantly less HIV stigma over time. In addition, those participants taking ARV medications experienced significantly higher HIV stigma over time compared to those not taking ARVs. This finding contradicts some authors' opinions that when clients enroll in ARV medication treatment it signifies that they are experiencing less stigma. This work provides caution to health care providers to alert clients new to ARV treatment that they may experience more stigma from their families and communities when they learn they are taking ARV medications.

Does perceived HIV stigma contribute to nurses' intent to migrate in five African countries?

Nurse migration out of low-resource countries has occurred for many years, resulting in workforce shortages, particularly in countries with a high prevalence of HIV. A cross-sectional survey of 1,374 nurses from five African countries (Lesotho, Malawi, South Africa, Swaziland, and Tanzania) was conducted. A logistic regression analysis resulted in a profile of odds ratios predicting increased odds of intent to migrate for nurses who were more experienced and working in urban hospitals. These data provide the first support that HIV stigma experienced by nurses through their association as providers for people living with HIV may also be contributing to their intent to migrate. The study contributes to a greater understanding of the complexity of nurse migration in Africa.

Men's and women's experiences with HIV and stigma in Swaziland

To explore how gender differentially affects the stigma experiences of people living with HIV (PLHIV) in Swaziland, the extent and dimensions of HIV-related felt and enacted stigma and social support were analyzed. Thirty-seven semistructured, face-to-face interviews were conducted with PLHIV in Swaziland between 2004 and 2006. Through the process of conceptual analysis, themes, including felt stigma, information management, enacted stigma, and social support, were explored, coded, and analyzed in the contexts of partner and familial relationships, and workplace and neighborhood settings. Findings revealed that there were high levels of felt stigma in all contexts, yet fewer than anticipated accounts of enacted stigma in family, work, and neighborhood contexts compared to their expressions of felt stigma. The amount and characteristics of felt and enacted stigma and social support differed based on gender, as women often experienced more felt and enacted stigma than men, and had less definite financial or emotional support.

One year after ART initiation: psychosocial factors associated with stigma among HIV-positive Mozambicans

The pathways through which stigma is associated with psychological distress remains understudied in Africa. This study evaluates stigma among 277 Mozambicans who were on an antiretroviral therapy (ART) regimens for a full year. Using bivariate and multiple regression analyses, we examine psychosocial factors (disclosure decisions, perceived social support, and depression) associated with stigma, at ART initiation and 1 year later. We found 1 year after initiating ART, participants reported no change in stigma, a decrease in perceived social support, and an increase in depressive symptomology. Disclosing HIV status to friends (versus family or partner) was associated with lower levels of stigma. These findings suggest that HIV care in comparable settings should include counselling, support groups, and peer support, that includes stigma and disclosure concerns prior to and during the first year following diagnosis. Most importantly, assessment and treatment of depression should be incorporated into ongoing HIV care.

Evaluation of a health setting-based stigma intervention in five African countries

The study aim is to explore the results of an HIV stigma intervention in five African health care settings. A case study approach was used. The intervention consisted of bringing together a team of approximately 10 nurses and 10 people living with HIV or AIDS (PLHA) in each setting and facilitating a process in which they planned and implemented a stigma reduction intervention, involving both information giving and empowerment. Nurses (n = 134) completed a demographic questionnaire, the HIV/AIDS Stigma Instrument-Nurses (HASI-N), a self-efficacy scale, and a self-esteem scale, both before and after the intervention, and the team completed a similar set of instruments before and after the intervention, with the PLHA completing the HIV/AIDS Stigma Instrument for PLHA (HASI-P). The intervention as implemented in all five countries was inclusive, action-oriented, and well received. It led to understanding and mutual support between nurses and PLHA and created some momentum in all the settings for continued activity. PLHA involved in the intervention teams reported less stigma and increased self-esteem. Nurses in the intervention teams and those in the settings reported no reduction in stigma or increases in self- esteem and self-efficacy, but their HIV testing behavior increased significantly. This pilot study indicates that the stigma experience of PLHA can be decreased, but that the stigma experiences of nurses are less easy to change. Further evaluation research with control groups and larger samples and measuring change over longer periods of time is indicated.

Perceived HIV stigma and life satisfaction among persons living with HIV infection in five African countries: a longitudinal study

BACKGROUND

Descriptive literature exists on the effects of HIV-related stigma on the lives of people living with HIV infection but few empirical studies have measured perceived HIV stigma nor explored its potential relationship to quality of life (QoL) over time in people living with HIV infection.

AIM

A cohort study of a purposive convenient sample of 1457 HIV-positive persons was followed for one year in a longitudinal design that examined the effects of stigma and the life satisfaction dimension of the HIV/AIDS Targeted Quality of Life Instrument (HAT-QOL) over time, as well as the influence of other demographic and assessed social variables. Data were collected three times about six months apart from December 2005 to March 2007.

RESULTS

The average age in this sample was 36.8 years (SD=8.78, n=1454) and 72.7% (n=1056) were female. The initial sample of participants was balanced among the five countries: Lesotho, Malawi, South Africa, Swaziland, and Tanzania. An attrition analysis demonstrated few demographic differences between those who remained in the study 12 months later compared with those at baseline. However, those who completed the study and who answered the QoL questions had significantly higher life satisfaction scores at baseline than those who left the study. There was a general increase in the report of life satisfaction QoL in all countries over the one-year period. However, as stigma scores increased over time there was a significant decrease in life satisfaction with differing rates of change by country. Certain factors had a positive influence on life satisfaction QoL: positive HIV media reports, taking antiretrovirals, reduced symptom intensity, and disclosure to a friend.

CONCLUSION

This cohort study is the first to document empirically in a longitudinal sample, that perceived HIV stigma has a significantly negative and constant impact upon life satisfaction QoL for people with HIV infection. In the absence of any intervention to address and reduce stigmatization, individuals will continue to report poorer life satisfaction evidenced by reduced living enjoyment, loss of control in life, decreased social interactivity, and decreased perceived health status.

Routine checks for HIV in children attending primary health care facilities in South Africa: attitudes of nurses and child caregivers

Management of HIV-infected and exposed children is challenging for health workers in primary care settings. Integrated management of childhood illness (IMCI) is a WHO/UNICEF strategy for improving morbidity and mortality in under 5 children attending first level facilities in developing countries. In high HIV-prevalence settings, IMCI includes an HIV component for identification and management of HIV-infected and exposed children, which requires health workers to ask all mothers about their HIV status and check all children for signs of HIV. Effective implementation of the HIV component depends on the ability and willingness of health workers to take every opportunity to identify HIV-infected children during routine care, and implementation in South Africa is poor. In 2006, we conducted 10 focus groups in two provinces in South Africa with IMCI-trained nurses, and with mothers attending first level facilities, to determine their attitudes towards, and experiences of, routine checks for HIV during consultations with sick children. Nurses were frequently unwilling to check for HIV in all children, believing it was unnecessary, unacceptable to mothers, and that they lack skills to implement HIV care. Nurses feared mothers would become upset or make a complaint. Mothers consistently recognised the importance of checking children for HIV and supported implementation of routine checks, although the attitude of the nurse was important in determining the acceptability of HIV-related questions. Mothers expressed fears about lack of confidentiality from nurses, and that receiving HIV-related services could lead to unintentional disclosure of their HIV status. Nurses lack the skills in HIV management and communication skills to implement the HIV component of IMCI. We identify issues relate to improved training, clear policies on record keeping, and organization of health services to respect privacy and confidentiality, to improve the willingness of health workers to provide HIV care and mothers to accept it.