The Framing and Fashioning of Therapeutic Citizenship Among People Living With HIV Taking Antiretroviral Therapy in Uganda

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis

INTRODUCTION

Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management.

METHODS

This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT).

RESULT

PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients.

CONCLUSION AND RECOMMENDATION

PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.

Practices of health citizenship in South Africa: a case study of the Treatment Action Campaign (TAC) in Khayelitsha, Cape Town

This article examines the Treatment Action Campaign's (TAC) evolution and attrition as a social movement organisation to discern its implications for practices of health citizenship at the grassroots level. A qualitative approach to case study research was used to collect and analyse data. Practices of health citizenship were framed around the integration of biomedical knowledge and people's experiences of grassroots activism. By exploring how the TAC's brand of activism filtered down to the community level, the findings reveal the importance of diverse forms of activist-led collective action in promoting health-seeking behaviour. These comprise activist-led branch meetings, community workshops, health promotion talks at clinics and community radio stations, as well as protest action at community clinics. Findings indicate that participation in TAC-led activism in Khayelitsha is not a passive form of responsible HIV citizenship. Rather, it is an active process through which TAC members integrate their lived experiences with biomedical knowledge to construct meanings and articulate grievances to enhance the quality of health service delivery in their community. Also, although the TAC's practices of health citizenship have not changed significantly over time, its campaigns have evolved based on contextual factors. These practices have entrenched ways of being, doing and knowing that have become an important resource for activist-led health promotion. Key stakeholders in government and civil society can harness these practices to strengthen health systems.

Understanding Patients' Experiences with a Brief Alcohol Reduction Intervention among People Living with HIV in Uganda: A Qualitative Study

Background: Brief alcohol reduction interventions for people living with HIV (PLWH) have resulted in mixed findings with some studies showing null or limited treatment effects. To better understand factors that may contribute to their success or failure, this qualitative study sought to explore participants' experiences in a randomized trial (RCT) of a brief counseling-based alcohol reduction intervention, including challenges that may have impeded alcohol reduction. Methods: We conducted in-depth semi-structured interviews with 24 PLWH engaging in unhealthy alcohol use, who were enrolled in an RCT to reduce alcohol consumption conducted in southwestern Uganda in 2019-2020 (NCT03928418). We used a collaborative thematic approach to analyze data from transcribed and translated audio recordings. Results: Perceived benefits of the intervention included increased awareness of alcohol use and its impact on personal finances, the relationship between alcohol use and violence, and a commitment to drinking reduction. Participants experienced several barriers to decreasing their alcohol use, including: prevailing social norms about alcohol use, lack of social support, and economic and social consequences of the COVID-19 pandemic. Conclusion: Factors in the immediate contexts of PLWH in low-income settings, including social norms influencing alcohol consumption and lack of social support, may impede the impact of alcohol reduction interventions, especially during times of stress such as the COVID-19 pandemic.

Biomedical bargains: Negotiating "safe sex" on antiretroviral treatment in rural South Africa

Wide-scale availability of antiretroviral treatment (ART) has transformed the global landscape for HIV prevention, shifting emphasis away from a strictly behavioral focus on changing sexual practices towards a biomedical approach. Successful ART management is measured by an undetectable viral load, which helps maintain overall health and prevent onward viral transmission. The latter utility of ART, however, must be understood in the context of its implementation. In South Africa, ART has become easily accessible - yet ART knowledge spreads unevenly, while counseling advice and normative expectations and experiences of gender and aging interact to inform sexual practices. As ART enters the sexual lives of middle-aged and older people living with HIV (MOPLH), a population growing rapidly, how has it informed sexual decisions and negotiations? Drawing on in-depth interviews with MOPLH on ART, corroborated with focus group discussions and national ART-related policies and guidelines, we find that for MOPLH, sexual decisions increasingly feature compliance with biomedical directives and concern for ART efficacy. Seeking consensus regarding the biological risks of sex on ART becomes an important feature of sexual negotiations, and anticipated disagreements can pre-empt sexual relationships altogether. We introduce the concept of biomedical bargains to explain what happens when disagreements arise, and the terms of sex are negotiated using competing interpretations of biomedical information. For both men and women, ostensibly gender-neutral biomedical discourses provide new discursive resources and strategies for sexual decisions and negotiations, yet biomedical bargains are still embedded in gender dynamics-women invoke the dangers of jeopardizing treatment efficacy and longevity to insist on condoms or justify abstinence, while men utilize biomedical arguments in an effort to render condomless sex safe. While the full therapeutic benefits of ART are critical for the efficacy and equity of HIV programs, they will nonetheless always affect, and be affected by, social life.

Citizenship in times of crisis: biosocial state-citizen relations during COVID-19 in Austria

Drawing upon 152 in-depth qualitative interviews with residents in Austria carried out in the first year of the pandemic, this article discusses how people's experiences with COVID-19 policies reflect and reshape state-citizen relations. Coinciding with a significant government crisis, the first year of COVID-19 in Austria saw pandemic measures justified with reference to a biological, often medical understanding of health that framed disease prevention in terms of transmission reduction, often with reference to metrics such as hospitalisation rates, etc. Instead of using this biomedical frame, our interviewees, however, drew attention to biopsychosocial dimensions of the crisis and problematised the entanglements between economy and health. We call this the emergence of a biosocial notion of citizenship that is attentive to psychological, social and economic dimensions of health. Insights into the biosocial nature of pandemic citizenship open a window of opportunity for addressing long-standing social injustices.

'Don't lose it on the bus!': Casting the normative biosexual citizen in early Scottish pre-exposure prophylaxis provision

The introduction of HIV pre-exposure prophylaxis (PrEP) raises important questions around how new biotechnologies are negotiated within contemporary settings and how they can shape the moral governance of biocitizens, or as we explore, biosexual citizens. This article draws on qualitative interviews and focus groups to consider how the normative biosexual citizen was cast at the start of provision in Scotland by clinical and community practitioners. Our findings show how practitioners navigated ideas around who was deserving of support and access to PrEP in the context of limited resources, interpreted what legitimate risk narratives might look like for different groups and translated particular gendered, sexualised and racialised risk profiles in the context of PrEP provision. This draws attention to how normative biosexual citizenship was not determined through meeting a set of clinical criteria and adhering to a prophylaxis regime but cast through ongoing negotiations with clinical and community practitioners in relation to normative ideas of essential care, constrained resources, risk narratives and gendered and racialised bodies. Our research indicates how access to PrEP will continue to demand particular enactments of normative biosexual citizenship that may well be at odds with the experiences and needs of communities affected by HIV.

Slipping through the cracks: a qualitative study to explore pathways of HIV care and treatment amongst hospitalised patients with advanced HIV in Kenya and the Democratic Republic of the Congo

Advanced HIV causes substantial mortality in sub-Saharan Africa despite widespread antiretroviral therapy coverage. This paper explores pathways of care amongst hospitalised patients with advanced HIV in rural Kenya and urban Democratic Republic of the Congo, with a view to understanding their care-seeking trajectories and poor health outcomes. Thirty in-depth interviews were conducted with hospitalised patients with advanced HIV who had previously initiated first-line antiretroviral therapy, covering their experiences of living with HIV and care-seeking. Interviews were audio-recorded, transcribed and translated before being coded inductively and analysed thematically. In both settings, participants' health journeys were defined by recurrent, severe symptoms and complex pathways of care before hospitalisation. Patients were often hospitalised after multiple failed attempts to obtain adequate care at health centres. Most participants managed their ill-health with limited support networks, lived in fragile economic situations and often experienced stress and other mental health concerns. Treatment-taking was sometimes undermined by strict messaging around adherence that was delivered in health facilities. These findings reveal a group of patients who had "slipped through the cracks" of health systems and social support structures, indicating both missed opportunities for timely management of advanced HIV and the need for interventions beyond hospital and clinical settings.

How the Term 'Self-Management' is Used in HIV Research in Low- and Middle-Income Countries: A Scoping Review

This scoping review assessed how the term 'self-management' (SM) is used in peer-reviewed literature describing HIV populations in low- and middle-income countries (LMIC). This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. OVID Medline, Embase, CAB Abstracts, and EBSCO CINAHL, Scopus, and Cochrane Library were searched up to September 2021 for articles with SM in titles, key words, or abstracts. Two team members independently screened the titles and abstracts, followed by the full-text. A data extraction tool assisted with collecting findings. A total of 103 articles were included. Since 2015, there has been a 74% increase in articles that use SM in relation to HIV in LMIC. Fifty-three articles used the term in the context of chronic disease management and described it as a complex process involving active participation from patients alongside providers. Many of the remaining 50 articles used SM as a strategy for handling one's care by oneself, with or without the help of community or family members. This demonstrates the varied conceptualizations and uses of the term in LMIC, with implications for the management of HIV in these settings. Future research should examine the applicability of SM frameworks developed in high-income settings for LMIC.

Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either ‘reputation’ or ‘respectability’. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.

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People living with HIV in Uganda hid their tobacco use from health workers.

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The experience of tuberculosis was the most common trigger to quit smoking.

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Engagement with ‘respectable’ masculinity promoted smoking cessation.

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Engagement with ‘reputational’ masculinity made it hard to quit.

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This model has wider applicability for antiretroviral therapy adherence.

Factors influencing self-management of adults living with HIV on antiretroviral therapy in Northwest Ethiopia: a cross-sectional study

BACKGROUND

Effective self-management is an important consideration for adults living with HIV on therapy to enable people to maintain their health and well-being whilst living with chronic HIV. Although numerous attempts have been made to implement and improve HIV self-management practice, there is limited evidence on effective self-management strategies, particularly in sub-Saharan Africa. This study aimed to identify the level and factors influencing the self-management practice of adults living with HIV on antiretroviral therapy.

METHODS

A cross-sectional survey was conducted on a sample of 415 adults living with HIV on antiretroviral therapy at a major referral hospital in Northwest Ethiopia using convenience sampling. A theory of self-management - the Individual and Family Self-Management Theory - guided the study design, analysis and presentation of the data. A face-to-face survey tool was administered for data collection, and the data were entered and analyzed using SPSS version 25.0.

RESULTS

Over half (58.1%) of the respondents were female. Many of the respondents did not know their HIV stage (76.9%) but reported adequate knowledge of their treatment (79.5%). The mean self-management score was 1.94+ 0.22 out of a total score of 3. Female gender was associated with decreased self-management. Contextual factors (gender, educational level, job status, income, living in a rural area, and awareness of HIV stage) explained 8.2% of the variance in self-management. The explanatory power increased by 9.2% when self-management process variables (self-efficacy, setting a goal, knowledge of antiretroviral therapy, HIV disclosure, and use of reminders) were added. Intervention-focused variables (encouraging disclosure and adherence support) increased the proportion of explained variance by 2.3%.

CONCLUSIONS

The findings of the study indicate that the level of self-management practice amongst the population studied was low compared to international literature. Our study findings support the theoretical model and previously identified factors influencing HIV self-management. The most important predictors of lower self-management practice in Ethiopia were female gender, illiteracy, lack of awareness of HIV stage, low self-efficacy, absence of reminders, lack of encouragement to disclose and absence of adherence support. HIV care providers should seek ways to empower and support adults living with HIV to self-manage, particularly through enhancing self-efficacy and encouraging the use of reminders.

"It was my obligation as mother": 18-Month completion of Early Infant Diagnosis as identity control for mothers living with HIV in Kenya

RATIONALE

Early Infant Diagnosis (EID) is critical to timely identification of HIV and rapid treatment initiation for infants found to be infected. Completing the EID cascade involves a series of age-specific tests between birth and 18 months and can be challenging for mother- infant pairs in low-resource settings. Even prior to recent increases in Kenya's testing recommendations, approximately 22% of mother-infant pairs enrolled in EID were lost to follow-up. As EID cascades become increasingly complex, identifying strategies to maximize retention becomes even more essential. Despite ongoing health system improvements, we still lack a framework for understanding the individual-level, psychosocial processes underlying EID completion-insight that could be essential for shaping strategies to support patients and close gaps in retention.

OBJECTIVE

Our objective was to explain individual-level processes that lead to EID completion among mothers who successfully completed the EID cascade.

METHODS

Using qualitative methods informed by grounded theory, we conducted 65 interviews with Kenyan mothers who completed EID.

RESULTS

We identified three themes related to completion: (1) Negative motivation, from the consequences of infant infection, fear of postnatal transmission, and burden of maternal failure; (2) Positive motivation, from achieving a final goal, responding to provider support, and maximizing infant health; and (3) Overcoming challenges, through resolve/resiliency, planning/privatizing and rejecting stigma/leveraging support.

CONCLUSION

Overall, the EID cascade served as a framing process for women to secure an identity as a good mother. Successful EID completion was the product of a strong motivational foundation channeled into strategies to surmount persistent challenges. Participant accounts of overcoming challenges highlight their resiliency as well as the outstanding need to address financial, logistical, and social barriers to care. Future EID programs may capitalize on these findings by affirming patients' quest for identity control, leveraging positive motivators, and expanding peer support structures to help mothers feel connected throughout the cascade.

Dissonance of Choice: Biomedical and Lived Perspectives on HIV Treatment-Taking

Treat-all recommends prompt treatment initiation for those diagnosed HIV positive, requiring adaptations to individuals' behavior and practice. Drawing on data from a longitudinal qualitative study in Eswatini, we examine the choice to initiate treatment when asymptomatic, the dissonance between the biomedical logic surrounding Treat-all and individuals' conceptions of treatment necessity, and the navigation over time of ongoing engagement with care. We reflect on the perspectives of healthcare workers, responsible for implementing Treat-all and holding a duty of care for their patients. We explore how the potentially differing needs and priorities of individuals and the public health agenda are navigated and reconciled. Rationalities regarding treatment-taking extend beyond the biomedical realm, requiring adjustments to sense of self and identity, and decision-making that is situated and socially embedded. Sense of choice and ownership for this process is important for individuals' engagement with treatment and care.

'My Tablets are on Top of the Fridge': The Roles of Relationship Desire and Medical Mistrust in ART Adherence for HIV-Positive MSM and Transgender Women Living in Rural South Africa

Given the high HIV prevalence for men who have sex with men (MSM) and transgender women in South Africa, there is limited understanding of social determinants that influence antiretroviral treatment (ART) adherence. Although universal testing and treatment (UTT) is available, ART adherence remains suboptimal. We conducted focus groups with MSM and transgender women in order to understand factors influencing their ART adherence in Mpumalanga, South Africa. All focus groups were audio-recorded, transcribed and translated for analysis using a constant comparison approach, guided by the concept of Therapeutic Citizenship. We found there is medical mistrust of ART based on differing interpretations of HIV cure that may influence treatment adherence behaviors within social networks, and relationship desire had a significant influence on optimal ART adherence. Our findings suggest that clinics must provide interventions that integrate HIV disclosure and relationship skill-building to support optimal ART adherence for MSM and transgender women under UTT.

Men's Refashioning of Masculine Identities in Uganda and Their Self-Management of HIV Treatment

Studies in sub-Saharan Africa show that masculine identities contribute to men's relatively lower uptake of HIV services. Although useful, these studies pay less attention to men's agency to negotiate and refashion masculine identities which better suit their lives as men living with HIV. In this article, I analyze the refashioning of masculine identities among men living with HIV in Uganda, adjustment processes which helped their self-management, and adherence to treatment. In-depth interviews with 18 men are thematically analyzed. Physical recovery was the embodiment of recovered masculinity and underpinned the men's ability to refashion alternative, hybrid masculinities. Men negotiated and refashioned two forms of dominant masculinity already identified in this context, respectability and reputation, notably being a responsible father again and supporting other men with HIV, and being strong, resilient and an HIV survivor. Understanding men's refashioning of masculinities can inform service providers' approaches to reach more men with HIV treatment.

Narrative Navigation: HIV and (Good) Care in Aceh, Indonesia

In this article, I elaborate the concept of narrative navigation to analyze the subjective and intersubjective ways in which people struggle through experiences of illness by constructing multiple, ambiguous and non-linear narratives that may continuously change, as they reposition themselves within changing circumstances. Drawing on ethnographic material on HIV care in Aceh, Indonesia, I show how subjunctivity and open-endedness are crucial narrative ways in which people living with HIV, their relatives, medical doctors and support group workers adjust to possibilities and limitations of care over time, thereby continuously negotiating what good care may be. Unfolding within a changing Indonesian healthcare system, their narrative navigations reveal caregiving to be a complex and contradictory process, thereby problematizing boundaries between good care and neglect.

Navigating HIV citizenship: identities, risks and biological citizenship in the treatment as prevention era

The use of HIV Treatment as Prevention (TasP) has radically changed our understandings of HIV risk and revolutionised global HIV prevention policy to focus on the use of pharmaceuticals. Yet, there has been little engagement with the very people expected to comply with a daily pharmaceutical regime. We employ the concept of HIV citizenship to explore responses by people living with HIV in the UK to TasP. We consider how a treatment-based public health strategy has the potential to reshape identities, self-governance and forms of citizenship, domains which play a critical role not only in compliance with new TasP policies, but in how HIV prevention, serodiscordant relationships and (sexual) health are negotiated and enacted. Our findings disrupt the biomedical narrative which claims an end to HIV through scaling up access to treatment. Responses to TasP were framed through shifting negotiations of identity, linked to biomarkers, cure and managing treatment. Toxicity of drugs - and bodies - were seen as something to manage and linked to the shifting possibilities in serodiscordant environments. Finally, a sense of being healthy and responsible, including appropriate use of resources, meant conflicting relationships with if and when to start treatment. Our research highlights how HIV citizenship in the TasP era is negotiated and influenced by intersectional experiences of community, health systems, illness and treatment. Our findings show that the complexities of HIV citizenship and ongoing inequalities, and their biopolitical implications, will intimately shape the implementation and sustainability of TasP.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

BACKGROUND

Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.

METHODS

We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.

RESULTS

We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.

CONCLUSION

This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

Being HIV positive and staying on antiretroviral therapy in Africa: A qualitative systematic review and theoretical model

BACKGROUND

Adherence to antiretroviral therapy (ART) and long-term uninterrupted engagement in HIV care is difficult for HIV-positive people, and randomized trials of specific techniques to promote adherence often show small or negligible effects. Understanding what influences decision-making in HIV-positive people in Africa may help researchers and policy makers in the development of broader, more effective interventions and policies.

METHODS

We used thematic synthesis and a grounded theory approach to generate a detailed narrative and theoretical model reflecting life with HIV in Africa, and how this influences ART adherence and engagement decisions. We included qualitative primary studies that explored perspectives, perceptions and experiences of HIV-positive people, caregivers and healthcare service providers. We searched databases from 1 January 2013 to 9 December 2016, screened all studies, and selected those for inclusion using purposeful sampling methods. Included studies were coded with Atlas.ti, and we assessed methodological quality across five domains.

RESULTS

We included 59 studies from Africa in the synthesis. Nine themes emerged which we grouped under three main headings. First, people who are HIV-positive live in a complicated world where they must navigate the challenges presented by poverty, competing priorities, unpredictable life events, social identity, gender norms, stigma, and medical pluralism-these influences can make initiating and maintaining ART difficult. Second, the health system is generally seen as punishing and uninviting and this can drive HIV-positive people out of care. Third, long-term engagement and adherence requires adaptation and incorporation of ART into daily life, a process which is facilitated by: inherent self-efficacy, social responsibilities, previous HIV-related illnesses and emotional, practical or financial support. These factors together can lead to a "tipping point", a point in time when patients choose to either engage or disengage from care. HIV-positive people may cycle in and out of these care states in response to fluctuations in influences over time.

CONCLUSION

This analysis provides a practical theory, arising from thematic synthesis of research, to help understand the dynamics of adherence to ART and engagement in HIV care. This can contribute to the design of service delivery approaches, and informed thinking and action on the part of policy makers, providers, and society: to understand what it is to be HIV-positive in Africa and how attitudes and the health service need to shift to help those with HIV lead 'normal' lives.

The role of children in their HIV-positive parents' management of antiretroviral therapy in Uganda

Adjustment to life on antiretroviral therapy (ART) and living with HIV as a long-term chronic condition, pose significant medical, social and economic challenges. We investigated children's role in supporting HIV-positive parents to self-manage life on ART. Between 2010 and 2012, we conducted a qualitative study using semi-structured interviews with 38 HIV-positive parents who had been on ART for over a year. They were randomly selected from people accessing ART from three delivery sites in Wakiso district, Uganda. Data were analysed thematically. Participants reported children between the ages of 1 and 47 years providing support. Children were a source of happiness, self-worth, encouragement, and comfort. Both younger and older children supported parents' adherence to treatment through reminding them to take the drugs and honour clinic appointments. Older children provided money to buy medication, food and shelter. Parents reported that the encouragement they received after they disclosed to their children enhanced their survival. After HIV disclosure to their children many of their fears about the future were allayed. Thinking about their children's future brought hope. However, looking after younger children while on ART could be burdensome since some parents could not work to their full capacity due to reduced physical health. Children are an important resource in their parents' adjustment to living with HIV while taking ART. There is a need for children to be supported by appropriate policy and other social and health development structures.

Redemption of the "spoiled identity:" the role of HIV-positive individuals in HIV care cascade interventions

Introduction

The concept of “therapeutic citizenship” has drawn attention to ways in which public testimony, the “story‐telling in the public sphere” undertaken by people living with HIV (PLHIV), has shaped the global response to the epidemic. This paper presents qualitative findings from two large studies in eastern Africa that reveal how the advent of population‐based HIV testing campaigns and efforts to accelerate antiretroviral “treatment for all” has precipitated a rapidly expanding therapeutic citizenship “project,” or social movement. The title of this paper refers to Goffman's original conceptualization of stigma as a social process through which a person's identity is rendered “spoiled.”

Methods

Data were derived from qualitative studies embedded within two clinical trials, Sustainable East African Research in Community Health (SEARCH) (NCT# 01864603) in Kenya and Uganda, and START‐ART (NCT# 01810289) in Uganda, which aimed to offer insights into the pathways through which outcomes across the HIV care continuum can be achieved by interventions deployed in the studies, any unanticipated consequences, and factors that influenced implementation. Qualitative in‐depth semi‐structured interviews were conducted among cohorts of adults in 2014 through 2015; across both studies and time periods, 217 interviews were conducted with 166 individuals. Theoretically informed, team‐based analytic approaches were used for the analyses.

Results

Narratives from PLHIV, who have not always been conceptualized as actors but rather usually as targets of HIV interventions, revealed strongly emergent themes related to these individuals' use of HIV biomedical resources and discourses to fashion a new, empowered subjecthood. Experiencing the benefits of antiretroviral therapy (ART) emboldens many individuals to transform their “spoiled” identities to attain new, valorized identities as “advocates for ART” in their communities. We propose that the personal revelation of what some refer to as the “gospel of ARVs,” the telling of personal stories about HIV in the public sphere and actions to accompany other PLHIV on their journey into care, is driven by its power to redeem the “spoiled identity:” it permits PLHIV to overcome self‐stigma and regain full personhood within their communities.

Conclusions

PLHIV are playing an unanticipated but vital role in the successful implementation of HIV care cascade interventions.

La vida normal: living with HIV in Santo Domingo, Dominican Republic

In this study, we explore how individuals living with HIV in the Dominican Republic strive to live a 'normal' life and the consequences of this pursuit of normalcy. We conducted qualitative in-depth interviews with men (n = 20) and women (n = 20) living with HIV and receiving care at two urban clinics in Santo Domingo. We analysed the data using a combination of narrative analysis and thematic coding. We aimed to identify how fears and/or lived experiences with social rejection and HIV-related stigma and discrimination shaped participants' abilities to maintain social relationships, be economically productive and manage HIV within the context of sexual relationships. Participants used the discourse of una vida normal (a normal life) to frame their response to HIV. This pursuit of normality was driven by the social and economic pressures of living with a chronic condition in a context of HIV-related stigma; trying to keep things 'normal' further added to these pressures. We argue that the normal life discourse fails to recognise the dynamic and complex nature of negotiating this condition and may also create additional burdens for individuals living with HIV that could impact their wellbeing and preventive behaviours.

Caregiver mental health and HIV-infected child wellness: perspectives from Ugandan caregivers

Prior studies indicate a substantial link between maternal depression and early child health but give limited consideration to the direction of this relationship or the context in which it occurs. We sought to create a contextually informed conceptual framework of this relationship through semi-structured interviews with women that had lived experience of caring for an HIV-infected child while coping with depression and anxiety symptoms. Caregivers explained their role in raising healthy children as complex and complicated by poverty, stigma, and isolation. Caregivers discussed the effects of their own mental health on child well-being as primarily emotional and behavioral, and explained how looking after a child could bring distress, particularly when unable to provide desired care for sick children. Our findings suggest the need for investigation of the reciprocal effects of child sickness on caregiver wellness and for integrated programs that holistically address the needs of HIV-affected families.

Long-Term Antiretroviral Treatment Adherence in HIV-Infected Adolescents and Adults in Uganda: A Qualitative Study

BACKGROUND

Long-term success of HIV antiretroviral therapy requires near-perfect adherence, maintained throughout one's lifetime. However, perceptions towards ART and patterns of adherence may change during the life course. We assessed challenges to long-term adherence in adolescents and adults in three regional HIV treatment centers in Uganda.

METHODS

We conducted 24 in-depth interviews and 2 focus group discussions with a total of 33 health-care providers and expert clients (HIV patients on long-term ART who assist with adherence support of fellow patients). Interview topics included experiences with patients on long-term treatment with either declining adherence or persistent poor adherence. Transcribed texts were coded and analyzed based on the social-ecological framework highlighting differences and commonalities between adolescents and adults.

RESULTS

The overarching themes in adolescents were unstructured treatment holidays, delays in disclosure of HIV status by caretakers, stigma, which was mainly experienced in boarding schools, and diminishing or lack of clinical support. In particular, there was minimal support for early and gradual disclosure for caretakers to the infected children, diminishing clinical support for young adults during transition to adult-based care and declining peer-to-peer support group activities. The predominating theme in adults was challenges with treatment access among temporary economic migrants. Common themes to adults and adolescents were challenges with disclosure in intimate relationships, treatment related factors including side effects, supply of single tablets in place of fixed-dose combined drugs, supply of drug brands with unfavorable taste and missed opportunities for counseling due to shortage of staff.

CONCLUSION

Adherence counseling and support should be adapted differently for adolescents and adults and to the emerging life course challenges in long-term treated patients. Programs should also address constraints experienced by temporary economic migrants to ensure continuity of treatment within the host country.

Routines, Hope, and Antiretroviral Treatment among Men and Women in Uganda

Antiretroviral treatment programs, despite biomedical emphases, require social understanding and transformations to be successful. In this article, we draw from a qualitative study of HIV treatment seeking to examine the drug-taking routines and health-related subjectivities of men and women on antiretroviral treatment (ART) at two sites in Uganda. We show that while not all participants in ART programs understand clinical protocols in biomedical terms, they adopt treatment-taking strategies to integrate medication into daily practices and social spaces. In turn, these embedded practices and understandings shape long-term hopes and fears for living with HIV, including the possibility of a cure. More significant than new forms of citizenship or sociality, we suggest that quotidian dimensions of treatment normalization shape the long-term experience of medication and outlook for the future.

Finding Meaning: HIV Self-Management and Wellbeing among People Taking Antiretroviral Therapy in Uganda

The health of people living with HIV (PLWH) and the sustained success of antiretroviral therapy (ART) programmes depends on PLWH’s motivation and ability to self-manage the condition over the long term, including adherence to drugs on a daily basis. PLWH’s self-management of HIV and their wellbeing are likely to be interrelated. Successful self-management sustains wellbeing, and wellbeing is likely to motivate continued self-management. Detailed research is lacking on PLWH’s self-management processes on ART in resource-limited settings. This paper presents findings from a study of PLWH’s self-management and wellbeing in Wakiso District, Uganda. Thirty-eight PLWH (20 women, 18 men) were purposefully selected at ART facilities run by the government and by The AIDS Support Organisation in and around Entebbe. Two in-depth interviews were completed with each participant over three or four visits. Many were struggling economically, however the recovery of health and hope on ART had enhanced wellbeing and motivated self-management. The majority were managing their condition well across three broad domains of self-management. First, they had mobilised resources, notably through good relationships with health workers. Advice and counselling had helped them to reconceptualise their condition and situation more positively and see hope for the future, motivating their work to self-manage. Many had also developed a new network of support through contacts they had developed at the ART clinic. Second, they had acquired knowledge and skills to manage their health, a useful framework to manage their condition and to live their life. Third, participants were psychologically adjusting to their condition and their new ‘self’: they saw HIV as a normal disease, were coping with stigma and had regained self-esteem, and were finding meaning in life. Our study demonstrates the centrality of social relationships and other non-medical aspects of wellbeing for self-management which ART programmes might explore further and encourage.