Trends in HIV Stigma Experienced by People Living With HIV in the Netherlands: A Comparison of Cross-Sectional Surveys Over Time

The expected impact of a cure for HIV among people with HIV and key populations

BACKGROUND

This study explored the expected impact of two hypothetical HIV cure scenarios on quality of life, sexual satisfaction, and stigma among people with HIV and key populations (i.e., partners and communities of people with HIV and men who have sex with men without HIV) in the Netherlands.

METHODS

A cross-sectional survey was conducted among people with HIV and key populations from October 2021 until June 2022. We assessed quality of life, sexual satisfaction, and stigma using linear regression and mixed models to compare participants' current situation with two hypothetical HIV cure scenarios: HIV post-intervention control, where HIV is suppressed without the need for ongoing antiretroviral treatment, but the viral reservoir is expected to persist, and HIV elimination, where HIV is completely removed from the body.

RESULTS

Our findings show that people with HIV (n = 222) expect improved quality of life and sexual satisfaction, as well as reduced stigma, compared to their current situation following both post-intervention control and elimination. Key populations (n = 495) similarly expect improvements for both HIV cure scenarios, except no expected improvement was found for quality of life following post-intervention control. Participants aged 18 to 34 anticipate greater improvements from both cure scenarios than those over 34.

CONCLUSIONS

Both people with HIV and key populations without HIV expect an HIV cure to have a positive impact on quality of life, sexual satisfaction, and stigma. This impact is expected not only for HIV elimination but also for HIV post-intervention control, the development of which appears more feasible.

High Prevalence of Posttraumatic Stress Disorder Symptoms Found in Well-Treated People with HIV after the Introduction of Patient-Reported Outcome Measures

People with HIV (PWH) are at greater risk of experiencing mental health problems, such as depression and post-traumatic stress disorder (PTSD). The purpose of our study was to determine the prevalence of posttraumatic stress disorder PTSD in PWH. PWH in care Amsterdam University Medical center (Amsterdam UMC) with access to the electronic patient portal were offered patient-reported outcome measures (PROMs) between May 2022 and May 2023, including the PC-PTSD-5 screen for PTSD as part of routine clinical care. Risk factors for a clinically relevant PC-PTSD-5 score were determined using univariate and multiple logistic regression analyses. Of 2476 PWH included, 1384 (55.9%) had access to the electronic patient portal of whom 474 (34.2%) completed the PC-PTSD-5. PWH without access to the patient portal were more often female, born in low- and middle-income countries, acquired HIV more often via heterosexual contact, and had worse HIV-related outcomes compared to those with access. Of 474 PWH who completed the PC-PTSD-5 screening question, 62 (13.1%) reached the threshold for clinically relevant PTSD. Age less than 50 years (OR 2.29, 95% CI: 1.21-4.35), and having originated from low- or middle-income countries (OR 2.02, 95% CI: 1.09-3.76) were associated with PTSD. Our findings show that 13% of PWH with a well-controlled HIV infection with access to the electronic patient portal at Amsterdam UMC experienced clinically relevant PTSD complaints.

Experiences with HIV stigma, among other barriers, in oral healthcare settings in Türkiye

Oral healthcare settings can be a challenging environment for people with HIV. Combined with problematic insurance policies, insufficient health literacy, and higher treatment fees, HIV stigma contributes to barriers when accessing oral healthcare. We conducted a descriptive study via an online survey with open-ended questions to understand the experiences of people with HIV in oral healthcare settings. The survey was administered by non-governmental organizations. Thematic analysis was used to analyze the data via a critical realist approach. Seventy-five participants responded to survey between August and September 2023. Thematic analysis yielded three main themes: occurrences of stigma in healthcare, coping with HIV stigma and anxiety, and barriers beyond stigma. Participants reported a problematic understanding of HIV literature and stigma among dentists, which was manifested as excessive precaution measures, denial of care, unnecessary referrals, gossiping, discriminatory remarks and disclosure of HIV status without consent. This was reflected in people with HIV as self-stigma, fear of healthcare workers and avoidance of healthcare services. Advancements in dental education and post-qualification training are needed in infection control and ethics, while people with HIV need health education to preserve their rights and sustain good health and well-being to prevent adverse outcomes.

Religion, Faith, and Spirituality as Barriers and Facilitators to Antiretroviral Therapy Initiation Among People with HIV in Indonesia

Indonesia is a country deeply rooted in religion, faith, and spirituality. These aspects significantly determine individuals' decision-making and behavior, including health care decisions. Given the suboptimal attainment of the HIV-cascade targets in the country, we conducted a study to explore the role of religion, faith, and spirituality on antiretroviral therapy (ART) initiation. Our study involved individual interviews with 67 participants recruited from community health centers, public hospitals, and private clinics, predominantly Muslim, including 17 untreated people with HIV (ART-naïve), 30 people with HIV on treatment (ART-experienced), and 20 HIV service providers. Findings revealed that many individuals perceived HIV as a godly punishment related to individual failure (prior risk-prone behaviors), generating shame, guilt, and stigma. Perceiving religion as punitive and unforgiving and holding fatalistic beliefs was linked to postponed ART initiation. Conversely, perceiving religion as loving and forgiving, seeking forgiveness through religious practices, viewing ART intake as a "collaborative" effort with God, and engaging in righteous deeds facilitated ART initiation. These findings indicated that religion, faith, and spirituality can serve as both barriers and facilitators to ART initiation, depending on individuals' faith-based practices and perceptions of religion, whether punishing or forgiving. We recommend that people with HIV and health care providers better recognize the role of religion, faith, and spirituality in coping with shame, guilt, and stigma after an HIV diagnosis. This recognition can facilitate informed decisions regarding ART initiation, ultimately improving health outcomes for individuals with HIV in Indonesia.

Healthcare providers' intention to discriminate against people with HIV

Background

Healthcare providers' discrimination practices against people with HIV is a real challenge for control and prevention efforts. The study aims to explore the association between healthcare providers' intention to discriminate against people with HIV and HIV stigma-related constructs, their sociodemographic, and occupation characteristics in Sudan.

Methods

A cross-sectional survey of healthcare providers was carried out in governmental hospitals in Kassala State, Sudan. Respondents completed measures assessing their intentions to discriminate against people with HIV, HIV-related stigma constructs, sociodemographic, and occupational characteristics. Bivariate and multiple linear regression analysis were used to assess the associations between discriminatory intentions against people with HIV and the studied variables.

Results

A total of 387 participants (223 physicians and 164 nurses) completed the survey. Participants had relatively high intentions to discriminate against people with HIV (M = 5.19, SD = 1.34-on a scale from 1 to 7), prejudiced attitudes (M = 4.70, SD = 1.29), internalized shame about HIV (M = 5.19, SD = 1.34), fear of HIV (M = 4.65, SD = 1.39), and the belief that patients with HIV do not deserve good care (M = 4.90, SD = 1.35). Healthcare providers' intention to discriminate against people with HIV was associated with prejudiced attitudes, internalized shame about HIV, fear of HIV, and the belief that people with HIV do not deserve good care. Female health care providers, nurses, and those with postgraduate degrees and fewer years of work experience were more likely to have a high intention to discriminate against people with HIV.

Conclusions

Intention to discriminate against people with HIV was high among healthcare providers. Addressing HIV-related stigma constructs and understanding the differential effects of healthcare providers' sociodemographic and occupational characteristics on their discriminatory intentions are imperative to developing effective intervention to reduce intention to discriminate against people with HIV among healthcare providers.

Transition experiences of young adults with perinatal HIV in the Netherlands

Introduction

The process of transition from paediatric to adult care is a crucial step towards self-management of healthcare for young adults with chronic health conditions. In the Netherlands, the On Your Own Feet program offers an extensive framework for supporting optimal transition. In this national study, we aimed to evaluate the transition experiences of young adults with perinatal HIV who transferred from a paediatric to an adult HIV treatment centre.

Methods

Participants who transferred to adult care less than six years ago received questionnaires on transition experiences, the validated On Your Own Feet - Transition Experiences Scale (OYOF-TES), and demographics. Demographic and healthcare-related variables were collected from patients' medical files. We explored correlations between OYOF-TES scores and other variables.

Results

Of 44 participants, 29 responded (65.1 %). Their median age was 20 (IQR 19-23). Overall, high scores were found on the subscales 'Reception in adult care' (median 4.8, IQR 4.0-5.0), 'Alliance paediatric and adult care' (median 4.0, IQR 3.4-4.4), and 'Transfer readiness' (median 4.2, IQR 3.8-4.8). The lowest scores were found in the subscales 'Preparation for transfer' (median 3.3, IQR 2.7-4.0) and 'Youth involvement' (median 3.5, IQR 2.5-4.5). Higher scores on transition experiences were correlated with younger age and female sex, while lower scores were correlated with those of whom one or both biological parents died during childhood.

Conclusion

Transition experiences in our population were positive. Younger participants felt better prepared for the transfer, which indicates that transition is increasingly becoming a joint effort between young adults and healthcare professionals and that pathways accustomed to individual needs improve the transition experience for young adults with perinatal HIV.

Access to HIV prevention, testing and care among people with a migration background in Euregio Meuse-Rhine: a needs and assets assessment

This study addresses disparities among people with a migration background (PMB) and those in less-urban regions, across the HIV prevention and care continuum (HIVPCC). We conducted a needs assessment and assets assessment to identify gaps between existing initiatives and persisting barriers. The research was conducted in the Euregio Meuse-Rhine (EMR), encompassing bordering regions in Belgium, Germany, and the Netherlands, and involved in-depth interviews with fifteen first-generation PMB, including nine with HIV. Six factors influencing PMB access to the HIVPCC were identified: past experiences with sexually transmitted infections (STIs) or HIV; HIV stigma and social dynamics; confidence and communication with healthcare providers and social workers; healthcare system navigation; precarity; and knowledge and beliefs about HIV/STIs. Existing assets mostly target individual or interpersonal levels, are often inaccessible due to language barriers, inadequately match PMB's living conditions and culture, and are irregular and hyperlocal. Recommendations include enhancing cultural sensitivity, adopting participatory approaches, tailoring outreach activities to legal situations and cultural context, and fostering cooperation between healthcare and social work institutions. This study underscores the importance of considering societal and institutional dynamics in bridging gaps in the HIVPCC for PMB, advocating for targeted interventions that promote inclusivity and equity.

The role of fear as a barrier and facilitator to antiretroviral therapy initiation in Indonesia: insights from patients and providers

Initiating antiretroviral therapy (ART) in Indonesia poses major challenges, with limited studies on specific ART initiation barriers and facilitators. Using a socioecological approach, we explored, through semi-structured interviews, the perspectives of 67 participants: 17 people with HIV not (yet) on ART, 30 people with HIV on treatment, and 20 HIV service providers (HSPs). Fears emerged as pervasive barriers to initiation encompassing, at the intrapersonal level, (irrational) fears of negative medical and non-medical consequences. At the health system level, fears were linked to concerns about bureaucracy and insufficient universal coverage. On a societal level, fears stemmed from prevalent myths, misinformation on social media, and the impact of COVID-19. Interestingly, fear also served as a facilitator to initiation. At the intrapersonal level, initiation was driven by a fear of deteriorating health or death due to AIDS-related conditions. At the interpersonal level, buddies and HSPs leveraged to motivate initiation. At the societal level, accurate yet fear-inducing information on social media stimulated initiation. Perspectives differed between people with HIV and HSP, with people with HIV emphasizing barriers on intrapersonal to health system levels, while HSP focused mostly on intrapersonal and interpersonal barriers, albeit recognizing the crucial role of health systems.

Knowledge, attitudes and beliefs regarding HIV among medical students in Zagreb, Croatia

BACKGROUND

Medical students, as future health-care providers (HCPs) play a significant role in shaping attitudes towards people living with HIV/AIDS (PLWHA) and should possess adequate knowledge of this infection. The study aim was to assess knowledge about HIV among medical students of the University of Zagreb School of Medicine, and to determine the level of discriminatory attitudes towards PLWHA.

METHODS

We assessed knowledge about epidemiology, treatment, and prevention of HIV by using closed-ended and multiple-choice questions. Likert-scale questions were employed to determine attitudes towards PLWHA. Bivariate and multivariate ordinal logistic regression was used to assess correlates of certain discriminatory attitudes.

RESULTS

561 medical students participated, with 46.7% attending preclinical courses. Overall, 42.1% of students think they received sufficient information on HIV/AIDS during elementary and high school education. Among clinical students, 42.6%, 20.8% and 11.8% estimated accurately transmission risk after a needle injury, unprotected vaginal, and anal intercourse, respectively. 66.8% of clinical students were aware that treatment can prevent AIDS, while 58.7% and 69.8% were familiar with the rationale of using pre-exposure (PrEP) and post-exposure prophylaxis (PEP). In the multivariate analysis, individuals lacking infectology course attendance (aOR = 1.45; CI: 1.00-2.09) and those unaware of transmission routes (aOR = 1.49; CI: 1.06-2.09) showed higher odds of advocating HIV status disclosure compared to those who did not yet attend an infectology course. Students supporting extra protection for handling PLWHA bodily fluids were more likely to support refusal to treat PLWHA (aOR = 1.80; CI: 1.22-2.69) compared to those who did not support that opinion. Males were more inclined to state that they would refuse to treat PLWHA (aOR = 1.66; CI: 1.11-2.50) and disclose their HIV status (aOR = 1.62; CI: 1.17-2.27) than females. Overestimating needle injury transmission risk raised treatment refusal likelihood (aOR = 2.22; CI = 1.29-3.92) compared to those accurately informed of this risk.

CONCLUSION

Results indicate lack of knowledge of HIV transmission risks after specific exposures and about PrEP, PEP and treatment effectiveness. Gender and knowledge about HIV transmission risks influence students' attitudes towards PLWHA. Medical education should be focused on fostering correct attitudes and addressing stigma, which undermines prevention and treatment outcomes of PLWHA.

Patient experiences with value-based healthcare interventions at the HIV outpatient clinic of the Erasmus Medical Centre

BACKGROUND

One of the aims of value-based healthcare (VBHC) is to deliver more patient-centred care. However, little is known about the effect of VBHC interventions on patient experiences. We aim to explore how patients experience VBHC as implemented in an HIV outpatient clinic in an academic hospital in the Netherlands.

METHODS

The HIV outpatient clinic of the Erasmus MC, Rotterdam, the Netherlands, an academic tertiary hospital, implemented a VBHC intervention consisting of 1) implementation of a generic quality of life questionnaire, administered before each visit, 2) a change in consultation schedule; from twice a year face-to-face to one face-to-face double consultation and one remote consultation per year, and 3) a change in consultation structure; from a single face-to-face consultation with the infectious diseases (ID) specialist to a double consultation in which the patient visits both the nurse and the ID specialist. Semi-structured interviews were held with Dutch or English-speaking adult patients, that had been a patient within Erasmus MC for more than 5 years, on their experiences with the implemented changes.

RESULTS

Thirty patients were interviewed. Patients had no objections towards completing the questionnaires especially if it could provide the professionals with additional information. Patients were primarily positive about the change in consultation schedule. For the yearly remote consultation they preferred a telephone-consultation above a video-consultation. The change in consultation structure ensured that more topics, including psychosocial and medical aspects could be discussed. Some patients did not see the added value of talking to two professionals on the same day or completing the quality of life questionnaire before their consultation.

CONCLUSION

Patients are generally positive towards the VBHC interventions implemented at the HIV outpatient clinic. Our findings may inform further optimization of VBHC interventions and improve patient-centred care in outpatient HIV clinics.

Opportunities for improved indicator-based HIV testing in the hospital setting: a structural equation model analysis

Indicator condition (IC)-guided HIV testing, i.e., testing when diagnosing a condition associated with HIV, is a feasible and cost-effective testing strategy to identify undiagnosed individuals. Assessing determinants for IC-guided testing may identify opportunities for improvement. A survey study based on the Theory of Planned Behaviour (TPB) was conducted among 163 hospital physicians from five specialties in Amsterdam, the Netherlands. Structural equation models were used to determine the association between the TPB domains (i.e., attitude, belief, norms, self-efficacy and behavioural control) and (1) the intention to test as a mediator for HIV testing behaviour (intentional model) and (2) actual HIV testing behaviour (direct model). Both models accounted for the effect of guideline recommendations. Behaviour scored lower than intention on a five-point scale (mean score of 2.8, SD = 1.6 versus 3.8, SD = 1.1; p<0.0001). The direct model had a better fit than the intentional model based on fit statistics. Discrepancies between the determinants most important for intention versus those for behaviour led to the following recommendations: interventions to improve IC-guided testing in hospitals should primarily focus on implementation of guideline recommendations, followed by improving physicians' attitude towards IC-guided HIV testing and self-efficacy, as these were the most important correlates of actual HIV testing behaviour.

Prevalence of HIV-related stigma manifestations and their contributing factors among people living with HIV in Sweden - a nationwide study

BACKGROUND

With access to  antiretroviral therapy (ART) HIV infection is a chronic manageable condition and non-sexually transmissible. Yet, many people living with HIV still testify about experiencing HIV-related stigma and discrimination. It is well-documented that HIV-related stigma and discrimination continue to be critical barriers to prevention, treatment, care and quality of life. From an individual stigma-reduction intervention perspective, it is essential to identify individual and interpersonal factors associated with HIV-related stigma manifestations. To address this issue and to expand the literature, the aim of this study was to assess the prevalence of HIV-related stigma manifestations and their associated factors among a diverse sample of people living with HIV in Sweden.

METHOD

Data from 1 096 participants were derived from a nationally representative, anonymous cross-sectional survey "Living with HIV in Sweden". HIV-related stigma manifestations were assessed using the validated Swedish 12-item HIV Stigma Scale encompassing four HIV-related stigma manifestations: personalised stigma, concerns with public attitudes towards people living with HIV, concerns with sharing HIV status, and internalized stigma. Variables potentially associated with the HIV-related stigma manifestations were divided into four categories: demographic characteristics, clinical HIV factors, distress and ART adherence, and available emotional HIV-related support. Four multivariable hierarchical linear regression analyses were employed to explore the associations between multiple contributors and HIV-related stigma manifestations.

RESULTS

The most dominating stigma feature was anticipation of HIV-related stigma. It was manifested in high scores on concerns with sharing HIV status reported by 78% of the participants and high scores on concerns about public attitudes towards people living with HIV reported by 54% of the participants. High scores on personalised stigma and internalized stigma were reported by around one third of the participants respectively. Between 23 and 31% of the variance of the four reported HIV-related stigma manifestations were explained mainly by the same pattern of associated factors including female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support.

CONCLUSION

The most dominating stigma feature was anticipation of stigma. Female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support constituted potential vulnerability factors of the four HIV-related stigma manifestations. Our findings highlight the vital necessity to support people living with HIV to increase their resilience to stigma in its different forms. Exploring associated factors of HIV-related stigma manifestations may give an indication of what circumstances may increase the risk of stigma burden and factors amenable to targeted interventions. As individual stigma-reductions interventions cannot be performed isolated from HIV-related stigma and discrimination in society, a key challenge is to intensify anti-stigma interventions also on the societal level.

Mpox stigma among men who have sex with men in the Netherlands: Underlying beliefs and comparisons across other commonly stigmatized infections

People with or at risk for mpox are likely to be stigmatized because of analogies to other sexually transmitted infections. Stigma is driven by beliefs about the perceived severity of the condition and perceived responsibility for acquiring the condition, both in broader society and individual responsibility. We explored these beliefs and compared them across mpox, human immunodeficiency virus (HIV), syphilis, gonorrhoea, and chlamydia in an online survey, conducted in July 2022, with 394 men-who-have-sex-with-men in the Netherlands. We compared mean scores between infections using repeated measures analysis of variance and conducted hierarchical regression analyses to identify determinants of both mpox perceived responsibility endpoints. Results showed that participants expected that mpox would be seen as a "gay disease" and will be used to blame gay men. Compared to other infections, mpox was considered less severe than HIV, but more severe than syphilis, gonorrhoea, and chlamydia. Perceived responsibility was comparable across infections, but, for each infection, participants perceived attributed responsibility to be higher in society than individual responsibility. Both perceived responsibility endpoints were highly correlated with each other and with other stigma beliefs. These results provide insight on the underlying determinants of mpox stigma and demonstrate that anticipated mpox stigma is present in the Netherlands.

Barriers and Facilitators to HIV Treatment Adherence in Indonesia: Perspectives of People Living with HIV and HIV Service Providers

HIV treatment adherence in Indonesia is a major challenge. Although previous studies have demonstrated several barriers and facilitators to adherence, studies providing a comprehensive analysis from both PLHIV and HIV service providers' perspectives are limited, especially in Indonesia. In this qualitative study with 30 people living with HIV on treatment (PLHIV-OT) and 20 HIV service providers (HSPs), we explored, via online interviews, the barriers and facilitators to antiretroviral therapy (ART) adherence using a socioecological approach. Both PLHIV-OT and HSPs reported stigma as a major barrier at each socioecological level, including public stigma at the societal level, stigma in healthcare settings, and self-stigma at the intrapersonal level. Stigma reduction must therefore be prioritized. PLHIV-OT and HSPs also reported support from significant others and HSPs as the foremost facilitators to ART adherence. The enablement of support networks is thus an important key to improved ART adherence. Overall, the societal level and health system barriers to ART adherence should be addressed in order to remove barriers and enhance the facilitators at the subordinate socioecological levels.

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.

Towards a better understanding of the social stigma of facial difference

Facial difference (FD) is not only an individual experience; it is inherently social, reflecting interactions between social norms and individual attitudes. Often FD is stigmatized. In this paper, we employ a widely used stigma framework, namely the social stigma framework put forth by Pryor and Reeder (2011), to unpack the stigma of FD. This framework posits that there are four forms of stigma: public stigma, self-stigma, stigma by association, and structural stigma. We first discuss the social and psychological literature on FD as it pertains to these various forms of stigma. We then describe coping approaches for FD stigma. Lastly, we delineate evidence-based methods for addressing the various forms of FD stigma, such that future efforts can more effectively tackle the stigma of facial difference.