Wakakosha "You are Worth it": reported impact of a community-based, peer-led HIV self-stigma intervention to improve self-worth and wellbeing among young people living with HIV in Zimbabwe

Exploring gender stereotypes and norms among peri-urban very young adolescents in Zimbabwe using participatory and qualitative approaches

Gender stereotypes and norms shape very young adolescents' (VYAs, 10-14 years old) behaviours, including in relation to sexual and reproductive health (SRH). This formative study sought to determine and prioritise the stereotypes and norms to be targeted as part of work to co-develop a gender-transformative intervention for VYAs in Zimbabwe to promote positive masculinities and SRH. In 2023, we collected data from VYAs, using participatory workshops encompassing various activities. We also held focus group discussions with older adolescents and parents/guardians, and individual interviews with community influencers. We used interpretive thematic analysis to generate themes across data. We later presented research findings to diverse stakeholders to explore how the findings might influence the design of our gender-transformative intervention. Gender stereotypes emerged in relation to sexual behaviour and SRH norms. Both boys and girls seemed to condone boys' multiple, concurrent relationships. Boys were deemed to be unable to control their sexual urges. Menstrual stigma, myths and misconceptions were pervasive. Stereotypes were also evident in beliefs and norms around resource and task allocation. For example, both boys and girls concurred that given limited resources, educating a boy child should be prioritised even when a girl sibling is performing better academically. Stereotypes relating to labour distribution were also evident. Daily activity charts suggested longer working hours for girls. Differential attitudes towards drug and substance use among boys and girls were driven by underlying masculine norms. Of note, adolescents disapproved of some of these norms, pointing to an opportunity to shift them. Stakeholders highlighted the need for our planned intervention to focus on the wider community, in addition to VYAs themselves. The formative research enabled us to identify key gender stereotypes and norms, information which is critical for informing the planned gender-transformative intervention. Although deeply seated, these stereotypes are not insurmountable, particularly among VYAs.

Assessing HIV treatment literacy among men living with HIV in Mozambique: a mixed-methods study to identify insights, gaps and impact from the 'Somos Iguais' campaign

OBJECTIVES

This study aimed to understand antiretroviral therapy (ART) adherence norms and beliefs among men living with HIV (MLHIV) in Mozambique, gauge the impact of misconceptions and harmful beliefs, evaluate perceived HIV service quality and assess the effectiveness of a behaviour change campaign (Somos Iguais), particularly among men aged 25-34 years.

DESIGN

A mixed-methods, cross-sectional study using quantitative and qualitative approaches.

SETTING

In Mozambique, over two million individuals live with HIV. This study was conducted in Maputo, Nampula and Sofala provinces.

PARTICIPANTS

The study comprised 10 focus group discussions with MLHIV aged 18-35 years and 58 indepth interviews with MLHIV aged 15-35 years across diverse subpopulations. A quantitative cross-sectional survey was completed by 1934 MLHIV aged 25-34 years.

INTERVENTION

Population Services International developed a behaviour change campaign in 2020 aimed at reaching men age 25-34, who often remain undiagnosed or not virally suppressed.

OUTCOME MEASURE

The study explores key aspects of HIV-related norms, behaviours and beliefs among people living with HIV, including high-risk subpopulations. These key aspects include misinformation, service quality gaps, perceived treatment benefits and the impact of the Somos Iguais campaign.

RESULTS

Significantly more MLHIV who were on ART believed that HIV treatment reduces the risk of transmission compared with those who were not on ART (33% and 10%, respectively; p<0.001). Few, however, understood that undetectable viral loads prevent transmission. This lack of understanding is associated with self-stigma and diminished motivation to stay on ART. More than half (54%) of the survey participants agreed that people who are suspected of having HIV lose respect in their community. Surprisingly, our findings did not suggest that provider stigma hampers ART adherence; instead, concerns centred around clinic privacy while obtaining ART. Many MLHIV received HIV education only after diagnosis at the clinic, highlighting a significant community knowledge gap that intensified stigma and hampered treatment. The Somos Iguais behaviour change campaign resonated well with men already on ART, but less so with those not on treatment.

CONCLUSION

While the study highlights a positive trend in HIV treatment literacy among MLHIV, it showed persistent stigmatising attitudes in the wider community. Investments to enhance knowledge and counter misconceptions about HIV treatment, especially among men not reached by the Somos Iguais campaign, are essential in expanding and sustaining the number of MLHIV virally suppressed on ART. Safeguarding patient confidentiality in clinics is imperative to encourage and sustain ART adherence.

Revealing the complexity of depression configurations in HIV-positive men who have sex with men: a fuzzy-set qualitative comparative analysis

BACKGROUND

Previous studies have explored the mental health of HIV-positive people. However, research specifically focusing on HIV-positive men who have sex with men (MSM) is relatively limited. From the configuration perspective, this study explored different combines influencing depression in HIV-positive MSM using fuzzy-set qualitative comparative analysis (fsQCA).

METHODS

Data was collected from April to July 2023. A total of 551 HIV-positive MSM served as valid samples. Participants completed electronic questionnaires, including information such as Family APGAR Index, Sense of Coherence Scale-13, Simplified Coping style Questionnaire, Templar's Death Anxiety Scale, Patient Health Questionnaire-9. This study simultaneously used two different analysis methods - linear regression model and fsQCA.

RESULTS

In the regression model, this study found that the sense of coherence has the greatest impact on depression. Through fsQCA, this study identified four configurations that may contribute to depression in HIV-positive MSM. The sense of coherence was a core condition in each configuration. In the configuration 1a most associated with depression, the sense of coherence was absent as a core condition, death anxiety and stigma were present as core conditions, and positive coping style was absent as a peripheral condition.

CONCLUSIONS

A higher sense of coherence is an important protective factor in reducing the risk of depression in HIV-positive MSM. Configurations formed by different variables all have a significant impact on depression in this study. In clinical intervention for depression of HIV-positive MSM, attention should be simultaneously paid to both internal psychological characteristics and external factors such as family environment.

Dynamic Network Analysis of Mental Health Symptoms Among Persons Living With HIV

AIM

This study aims to develop dynamic networks and examine the longitudinal relationships of mental health symptoms among persons living with HIV (PLWH).

DESIGN

A longitudinal study.

METHODS

We collected data between October 2022 and December 2022 using Wenjuanxing (Questionnaire Star), an online survey platform. The study tracked weekly data across 10 sessions, involving 123 PLWH in Beijing, China. A total of 40 mental health symptoms with six dimensions (somatization symptoms, negative affect, cognitive processes, cognitive function, interpersonal communication and social adaptation) were included in the symptom network, which consists of temporal, contemporaneous and between-person networks.

RESULTS

In the temporal network, 'feeling inferior to others' had the largest in-strength value, whereas 'suicidal ideation' exhibited the largest out-strength value. In the contemporaneous network, 'feeling inferior to others' showed the highest bridge strength, indicating it had the most connections to other mental health symptoms.

CONCLUSIONS

We found that 'feeling inferior to others' had the highest number of predictors, with up to seven mental health symptoms potentially triggering this particular symptom. Additionally, 'suicidal ideation' emerged as a powerful predictor, influencing the greatest number of mental health symptoms across five dimensions.

IMPACT

Our study enhances the understanding of the sequential development and consequences of mental health symptoms among PLWH, which may provide an important basis for designing precise mental health symptom management interventions.

REPORTING METHOD

This study was reported according to the STROBE checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Mental health and other clinical and social characteristics of young mothers living with HIV in Zimbabwe: a mixed-methods study

Young women living with HIV (YWLHIV) experience numerous stressors including treatment management and poor parent modelling. We investigated YWLHIV's mental health and other clinical and social characteristics to inform tailored support. YWLHIV (15-24 years old) participating in a peer-support model tailored for young mothers (Young Mentor Mum intervention) completed a self-administered interview and had clinical and psychological assessments in March to April 2019. A subset participated in in-depth interviews and had their partners interviewed. We analysed quantitative and qualitative data using STATA 15 and thematic analysis, respectively. We enrolled 177 YWLHIV. We found high rates of maternal viral suppression (86.9% with viral load <1000 copies/ml). Over half were at risk of common mental disorder (CMD), scoring above the cut-off point (SSQ ≥8, 50.3%) and depression (EPDS ≥12, 55.9%). CMD risk was higher among women who reported intimate partner violence in the past year (64.1% vs 39.4%; adjusted OR 2.48 (1.12, 5.48) for violence 1-2 times and 2.41 (0.99-5.85) for higher frequency; p = .03). HIV status disclosure was limited; only 44.1% had disclosed to their partners. YWLHIV confront challenges which affect their health and that of their children. Youth-focused mental health interventions coupled with couples counselling and violence prevention need to be scaled up.

Clinical and psychosocial context of HIV perinatally infected young mothers in Harare, Zimbabwe: A longitudinal mixed-methods study

BACKGROUND

The lives of adolescents and young people living with HIV (LHIV) are dominated by complex psychological and social stressors. These may be more pronounced among those perinatally infected. This longitudinal mixed-methods study describes the clinical and psychosocial challenges faced by HIV perinatally infected young mothers in Harare, Zimbabwe to inform tailored support.

METHODS

HIV perinatally infected young mothers were recruited in 2013 and followed up in 2019. In 2013, they completed a structured interview, clinical examination, psychological screening and had viral load and drug resistance testing. A subset completed in-depth interviews (n = 10). In 2019, they were re-interviewed and had viral load testing. Data were analyzed using STATA 15.0. and thematic analysis.

RESULTS

Nineteen mothers aged 17-24 years were recruited in 2013. Eleven (57.9%) were successfully recontacted in 2019; 3 had died, 2 had relocated and 3 were untraceable. In 2013, all 19 mothers were taking antiretroviral therapy (median duration 8 years, range 2-11 years) and median CD4 count was 524 (IQR 272). In 2013, eight mothers (42.1%) had virological failure (≥1000 copies/ml) (3 of whom subsequently died) and 7 (36.8%) had evidence of drug resistance. In 2019, the proportion with virological failure was 2/11 (18.1%). Six of 11 (54.5%) had switched to second line therapy. In 2013, 64.3% were at risk of common mental disorder and this risk was higher at follow-up (72.7%). Qualitative data highlighted three pertinent themes: HIV status disclosure, adherence experiences and, social and emotional support.

CONCLUSIONS

Findings from this study underscore the significant clinical, social and psychological challenges faced by perinatally infected young mothers. The high rates of virological failure, drug resistant mutations, mental health issues and mortality observed in this population indicate the need for tailored and comprehensive health and support services to assist these young mothers.

"I realized I had a choice": the forgiveness journey of people living with HIV

ABSTRACTForgiveness, a process of relinquishment of resentment, hostility, and anger toward an offender or self, is understudied among people living with HIV. This study examined the experience and process of forgiving the person who allegedly transmitted HIV, among people living with HIV. In-depth interviews were conducted with 14 people living with HIV aged 25 or older, diagnosed at least three years before the study. Three main themes emerged: "Anger is a poison": between forgiveness and unforgiveness; "I gave up the drive to suffer": the meaning of forgiveness; and "Forgiving is like building a building": phases of the forgiveness process between forgiveness and unforgiveness. This study revealed cognitive and emotional processes and phases of forgiveness. Forgiveness-focused interventions for people living with HIV are suggested.

A scoping review on peer-led interventions to improve youth mental health in low- and middle-income countries

Youth living in low- and middle-income countries (LMICs) have an increased vulnerability to mental illnesses, with many lacking access to adequate treatment. There has been a growing body of interventions using task sharing with trained peer leaders to address this mental health gap. This scoping review examines the characteristics, effectiveness, components of peer delivery and challenges of peer-led mental health interventions for youth aged 10-24 in LMICs. A key term search strategy was employed across MEDLINE, Embase, Web of Science, Global Health and Global Index Medicus. Eligibility criteria included young people aged 10-24 and a peer-led component delivered in any setting in an LMIC. Study selection and extraction were conducted independently by the first and second authors, with discrepancies resolved by the senior author. Study characteristics were summarised and presented descriptively. The search identified 5,358 citations, and 19 studies were included. There were 14 quantitative, four qualitative and one mixed methods study reporting mental health outcomes. Types of interventions were heterogenous but fell within three broad categories: (1) peer education and psychoeducation, (2) peer-led psychotherapy and counselling and (3) peer support. All studies reported improved mental health outcomes as a result of the peer-led interventions. Peer-led interventions are versatile in terms of both the types of interventions and mode of delivery. Lived experience, mutual respect and reduced stigma make this method a highly unique and effective way to engage this age group. However, implementing peer-led youth interventions is not without challenges. Adequate training, supervision, cultural appropriateness and support from established institutions are critical to safeguarding and ensuring the sustainability of such programs. Our findings suggest that peer-led models are a valuable intervention strategy that policymakers can leverage in current and future efforts to address youth mental health in LMICs. Future areas of research should expand to include the perspectives of other key stakeholders involved in the implementation of peer-led mental health interventions, focusing on factors including fidelity, feasibility and acceptability to enhance implementation insights.

Reported impact of creativity in the Wakakosha ('You're Worth It') internal stigma intervention for young people living with HIV in Harare, Zimbabwe

Internal stigma (negative judgements towards oneself) continues to be a barrier to HIV treatment, management and care, and has global public health consequences. People living with HIV (PLHIV) who report internal stigma are less likely to seek care, adhere to treatment and can experience increased depression and lower quality of life. The Wakakosha ('You're Worth It') programme sought to reduce internal stigma among young PLHIV using inquiry-based stress reduction (IBSR), a cognitive and awareness-based methodology. This sub-study focused on creativity, exploring how it promotes young PLHIV's well-being. We analysed individual interviews (n = 14), focus groups (n = 3), poems (n = 5), songs (n = 2) and self-compassion letters (n = 38) and 23 activity journals from November 2021 to March 2022, utilising inductive thematic analysis to identify themes across the data. Creativity saturated the Wakakosha intervention through modalities such as drawing, colouring, body mapping, music and letter writing. These engaged participants and gave them a space in which to shift their internal stigmatising beliefs, and helped them in multiple ways including: facilitating emotional regulation, self-acceptance, self-compassion, self-worth and body positivity. Creativity also enhanced participants' self-image and allowed them to see their own abilities. Music improved the therapeutic environment by helping participants focus, emote, retain messages and connect within the group setting. Letters to self/others allowed participants to let go of stigma towards themselves and the circumstances of their infection. Tools such as drawing and body mapping assisted participants with emotional recognition and expression. This sub-study provided insight into the potential of creativity, when integrated into an IBSR intervention, in counteracting internal stigma. Ongoing replication is needed to continue to evolve best practices for internal stigma interventions. Future work should use more structured and specific interviews with participants regarding their creative processes.

A conceptualization and psychometric evaluation of positive psychological outcome measures used in adolescents and young adults living with HIV: A mixed scoping and systematic review

INTRODUCTION

Sub-Saharan Africa bears the greatest burden of HIV, with comorbid mental conditions highly prevalent in people living with HIV. It is important to evaluate the mental health of adolescents and young adults living with HIV (AYALHIV) comprehensively by measuring both negative and positive psychological constructs. There has been a proliferation of interest in positive psychological outcome measures, but the evidence of their psychometric robustness is fragmented. This review sought to: 1) Identify positive psychological outcomes and corresponding outcome measures used in AYALHIV in sub-Saharan Africa. 2) Critically appraise the psychometrics of the identified outcome measures.

METHODS AND ANALYSIS

Two reviewers independently searched articles in PubMed, Scopus, Africa-Wide Information, CINAHL, Psych INFO and Google Scholar. Searches were conducted from November 2022 to February 2023. Two separate reviewers independently reviewed retrieved articles. We applied a narrative synthesis to map the key constructs. The risk of bias across studies was evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. The quality of the psychometric properties was rated using the COSMIN checklist and qualitatively synthesized using the modified Grading of Recommendations Assessment, Development, and Evaluation checklist.

RESULTS

We identified 15 positive psychological constructs: body appreciation, confidence, coping, flourishing, meaningfulness, personal control, positive outlook, resilience, self-management, self-compassion, self-concept, self-efficacy, self-esteem, self-worth and transcendence, that had been used to assess ALHIV. The most measured constructs were resilience, self-concept, self-esteem, coping and self-efficacy. Construct validity and internal consistency were the properties most frequently considered, while content validity and structural validity were assessed less often.

CONCLUSIONS

Few studies performed complete validations; thus, evidence for psychometric robustness was fragmented. However, this review shows the initial evidence of the feasibility of using positive psychological outcomes in low-resource settings. Instead of creating new outcome measures, researchers are recommended to leverage the existing measures, adapt them for use and, if appropriate, strive to maintain the factorial structure to facilitate comparisons.

REGISTRATION

PROSPERO-CRD42022325172.

Stigma and fear of getting sick in the care of people living with HIV: an exploratory systematic review

The aim of the present study was to explore the stigma and fear of getting sick in health professionals who treat people living with HIV. An exploratory systematic review was conducted. The search was limited to the presence of stigma and fear of getting sick on the part of healthcare workers who treat people living with HIV, documented by the health workers or patients themselves. No language restriction was made and systematic reviews, comments or communications were excluded. The sources of information were Scopus, PubMed/MEDLINE, Science Direct, and the CENTRAL Registry, from the last 5 years. The quality of the evidence was assessed with an adapted tool and the synthesis of the results was carried out using a narrative synthesis approach. Twenty-three articles were included, which related structural stigma, stigma by health professionals and fear of getting sick. Among the findings, data stood out such as that more than 50% of patients reported having experienced discrimination due to HIV and even accumulated stigma for other additional causes. Stigma enacted in healthcare settings was related to suboptimal adherence to treatment (OR 1.38; 95% CI: 1.03-1.84; p=0.028). Stigma is a structural barrier in the care of people living with HIV and generates a psychological, physical, and social health impact for these people. Some limitations of the present study are that, despite searching the major databases, important manuscripts may have been left out. Additionally, there are regions that are not represented in this review because no manuscripts from those areas were found.

Leaving no one behind? Addressing inequitable HIV outcomes by attending to diversity: A qualitative study exploring the needs of LGBTQI+ young people living with HIV in Zimbabwe

Leaving nobody behind in the fight to end the HIV epidemic as a public health threat depends on addressing inequities in optimal HIV outcomes. Consistently overlooked in research, policy and programming are young lesbian, gay, bisexual, transgender, queer/questioning and intersex (LGBTQI+) people who are living with HIV. This study engaged young LGBTQI+ people in Zimbabwe to better understand their experiences of living with HIV and the support they need. Between September 2022 and February 2023, we conducted qualitative research with 14 LGBTQI+ young people (18-24 years), (two focus group discussions and in-depth interviews with 5/14). All 14 participants were accessing a LGBTQI+ HIV support group at Zvandiri ('As I Am'), a well-established community-based HIV program. We conducted thematic analysis and key findings informed the collaborative development of internal activities to further enhance inclusivity of LGBTQI+ young people within Zvandiri's programs. There was consensus among participants that being LGBTQI+ and living with HIV leads to "double stigma and double trouble", involving physical and verbal harassment, social exclusion and family rejection. Participants concealed their LGBTQI+ identity and HIV status in most situations, and many withheld their HIV status in LGBTQI+ social spaces, including community-led LGBTQI+ services. This negatively impacted their psychosocial well-being and social connectedness. Participants described positive experiences of Zvandiri. Interacting with others living with HIV in a destigmatising environment promoted self-acceptance. However, reflecting their prevailing experiences, participants were cautious about revealing their sexuality and/or gender identity at Zvandiri outside of their support group. Ensuring equitable access to HIV care, including mental health support, relies on understanding the challenges experienced by those most marginalised. Critically important is understanding the impact of intersectional stigma on LGBTQI+ young peoples' social lives, and their access to services. Community-based HIV support programs are well-positioned to support and advance this group's health rights.