1
|
De Villiers L, Swartz L, Bock P, Seeley J, Stangl AL, Bond V, Hargreaves J, Hoddinott G. HIV and gender identity expression among transfeminine women in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial. Res Sq 2023:rs.3.rs-2486896. [PMID: 36798211 PMCID: PMC9934773 DOI: 10.21203/rs.3.rs-2486896/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction Transfeminine women in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine women and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming. Methods A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine women (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We discuss gender identification presented in participants' daily lives and in relation to HIV service access. Results Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members, but amongst peers, they expressed a more effeminate identity and with partners they took on a feminine identity. Conclusions Our findings are amongst the first exploratory and descriptive data of transfeminine women in South Africa. We show how transfeminine women navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.
Collapse
|
2
|
Shrestha A, Stangl AL, Paneru B, Poudel L, Karmacharya A, Makaju S, Spiegelman D, Shakya S, Shrestha AD, Sheth S. Validation of the Cancer Stigma Scale in Nepalese Women. Asian Pac J Cancer Prev 2023; 24:207-214. [PMID: 36708569 PMCID: PMC10152840 DOI: 10.31557/apjcp.2023.24.1.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Cancer stigma is known to have an adverse impact on cancer patients as well as vulnerable groups who are at risk of developing cancer. In Nepal, there is no validated instrument for assessing cancer stigma and there has been relatively little research examining the stigmatization of cancer among the Nepalese population. OBJECTIVE We aimed to validate the Cancer Stigma Scale (CASS) among apparently healthy Nepali women. METHODS We interviewed 426 Nepali women after the translation, back-translation, and cross-cultural adaptation of the CASS into Nepali. We assessed internal consistency using Cronbach's alpha and assessed model fit using confirmatory component analysis. RESULTS The Nepali CASS had satisfactory internal reliability, Cronbach's alpha of the overall scale and six components was 0.88 and 0.70-0.89, respectively. Confirmatory factor analysis confirmed the six-factor structure (RMSEA = 0.074, GFI = 0.864, AGFI = 0.825, CFI = 0.901, NFI = 0.866, χ2/df=3.341). Having no formal education was associated with higher levels of stigma related to avoiding cancer patients and attributing cancer to personal responsibility. CONCLUSIONS The Nepali CASS demonstrated sufficient internal consistency, reliability, and model fit indices, making it suitable for assessing cancer stigma among Nepali people.
Collapse
Affiliation(s)
- Archana Shrestha
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal.,Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA.,Institute for Implementation Science and Health (IISH), Kathmandu, Nepal.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, USA
| | - Anne L Stangl
- Hera Solutions, Baltimore, MD, USA.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Bandana Paneru
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Lisasha Poudel
- Institute for Implementation Science and Health (IISH), Kathmandu, Nepal
| | - Aerona Karmacharya
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Soniya Makaju
- Department of Public Health and Community Programs, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Donna Spiegelman
- Department of Biostatistics and Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA
| | - Sunila Shakya
- Department of Obstetrics and Gynecology, Dhulikhel Hospital-Kathmandu University Hospital, Dhulikhel, Nepal
| | - Aamod Dhoj Shrestha
- Center for Global Health, Department of Public Health, Aarhus University, Aarhus, Denmark.,COBIN, Nepal Development Society, Bharatpur, Nepal
| | - Sangini Sheth
- Department of Obstetrics, Gynecology & Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA
| |
Collapse
|
3
|
Stangl AL, Atkins K, Leddy AM, Sievwright KM, Sevelius JM, Lippman SA, Veras MA, Zamudio-Haas S, Smith MK, Pachankis JE, Logie CH, Rao D, Weiser S, Nyblade L. What do we know about interventions to reduce intersectional stigma and discrimination in the context of HIV? A systematic review. Stigma and Health 2022. [DOI: 10.1037/sah0000414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
4
|
Sievwright KM, Stangl AL, Nyblade L, Lippman SA, Logie CH, Veras MADSM, Zamudio-Haas S, Poteat T, Rao D, Pachankis JE, Kumi Smith M, Weiser SD, Brooks RA, Sevelius JM. An Expanded Definition of Intersectional Stigma for Public Health Research and Praxis. Am J Public Health 2022; 112:S356-S361. [PMID: 35763723 PMCID: PMC9241457 DOI: 10.2105/ajph.2022.306718] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Kirsty M Sievwright
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Anne L Stangl
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Laura Nyblade
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Sheri A Lippman
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Carmen H Logie
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Maria Amélia de Sousa Mascena Veras
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Sophia Zamudio-Haas
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Tonia Poteat
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Deepa Rao
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - John E Pachankis
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - M Kumi Smith
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Sheri D Weiser
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Ronald A Brooks
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Jae M Sevelius
- Kirsty M. Sievwright and Anne Stangl are with the Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Laura Nyblade is with the Global Health Division, International Development Group, RTI International, Washington, DC. Sheri A. Lippman, Sophia Zamudio-Haas, Sheri Weiser, and Jae M. Sevelius are with the Department of Medicine, University of California, San Francisco. Carmen H. Logie is with the Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Canada. Maria Amélia Veras is with the Collective Health, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil. Tonia Poteat is with the Department of Social Medicine, University of North Carolina School of Medicine, Chapel Hill. Deepa Rao is with the Department of Global Health, University of Washington, Seattle. John E. Pachankis is with the Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT. M. Kumi Smith is with the Department of Epidemiology & Community Health, University of Minnesota Twin Cities, Minneapolis. Ronald Brooks is with the Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles
| |
Collapse
|
5
|
Stangl AL, Pliakas T, Izazola-Licea JA, Ayala G, Beattie TS, Ferguson L, Orza L, Mathur S, Pulerwitz J, Iovita A, Bendaud V. Removing the societal and legal impediments to the HIV response: An evidence-based framework for 2025 and beyond. PLoS One 2022; 17:e0264249. [PMID: 35192663 PMCID: PMC8863250 DOI: 10.1371/journal.pone.0264249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/07/2022] [Indexed: 02/04/2023] Open
Abstract
Societal and legal impediments inhibit quality HIV prevention, care, treatment and support services and need to be removed. The political declaration adopted by UN member countries at the high-level meeting on HIV and AIDS in June 2021, included new societal enabler global targets for achievement by 2025 that will address this gap. Our paper describes how and why UNAIDS arrived at the societal enabler targets adopted. We conducted a scoping review and led a participatory process between January 2019 and June 2020 to develop an evidence-based framework for action, propose global societal enabler targets, and identify indicators for monitoring progress. A re-envisioned framework called the '3 S's of the HIV response: Society, Systems and Services' was defined. In the framework, societal enablers enhance the effectiveness of HIV programmes by removing impediments to service availability, access and uptake at the societal level, while service and system enablers improve efficiencies in and expand the reach of HIV services and systems. Investments in societal enabling approaches that remove legal barriers, shift harmful social and gender norms, reduce inequalities and improve institutional and community structures are needed to progressively realize four overarching societal enablers, the first three of which fall within the purview of the HIV sector: (i) societies with supportive legal environments and access to justice, (ii) gender equal societies, (iii) societies free from stigma and discrimination, and (iv) co-action across development sectors to reduce exclusion and poverty. Three top-line and 15 detailed targets were recommended for monitoring progress towards their achievement. The clear articulation of societal enablers in the re-envisioned framework should have a substantial impact on improving the effectiveness of core HIV programmes if implemented. Together with the new global targets, the framework will also galvanize advocacy to scale up societal enabling approaches with proven impact on HIV outcomes.
Collapse
Affiliation(s)
- Anne L. Stangl
- Hera Solutions, Baltimore, MD, United States of America
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Triantafyllos Pliakas
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Impact Epilysis, Thessaloniki, Greece
| | | | - George Ayala
- Alameda County Public Health Department, Oakland, CA, United States of America
- MPact Global Action for Gay Men’s Health and Rights, Oakland, CA, United States of America
| | - Tara S. Beattie
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Laura Ferguson
- Institute on Inequalities in Global Health, University of Southern California, Los Angeles, CA, United States of America
| | - Luisa Orza
- Frontline AIDS, Brighton, United Kingdom
| | - Sanyukta Mathur
- Population Council, Washington, DC, United States of America
| | - Julie Pulerwitz
- Population Council, Washington, DC, United States of America
| | | | - Victoria Bendaud
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| |
Collapse
|
6
|
Stangl AL, Mwale M, Sebany M, Mackworth-Young CR, Chiiya C, Chonta M, Clay S, Sievwright K, Bond V. Feasibility, Acceptability and Preliminary Efficacy of Tikambisane ('Let's Talk to Each Other'): A Pilot Support Group Intervention for Adolescent Girls Living With HIV in Zambia. J Int Assoc Provid AIDS Care 2021; 20:23259582211024772. [PMID: 34212766 PMCID: PMC8255553 DOI: 10.1177/23259582211024772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: In Zambia, 84,959 adolescent girls and young women (AGYW) aged 15-24 are currently living with HIV. We explored the feasibility and acceptability of a 6-session, curriculum-based support group intervention designed to address key concerns of AGYW living with HIV. Setting: Urban Zambia Methods: Surveys and in-depth interviews were collected pre- and post-intervention from participants enrolled from 2 health facilities. Eight participant observations of sessions were conducted. Descriptive statistics at baseline were reported only for AGYW who participated in the intervention (N = 21), while analyses comparing baseline and endline outcome measures were restricted to participants who had data at both time points (N = 14). Results: Support groups were feasible to conduct and acceptable to participants. Co-facilitation by an adult counselor and peers living with HIV raised confidence about session content. Sessions on antiretroviral therapy (ART), disclosure and stigma, and grief and loss were most in demand. We did not observe significant differences in key outcome measures between baseline and follow-up. However, qualitative data supported the positive impact of the intervention on ART adherence and hope for the future following the intervention among our participants. Conclusion: A short-term, structured support group series holds promise for helping AGYW living with HIV safely navigate a complex time in their lives.
Collapse
Affiliation(s)
- Anne L Stangl
- Department of Global Health, Youth and Development, International Center for Research on Women, Washington DC, USA.,Hera Solutions, Owings Mills, MD, USA
| | - Mwangala Mwale
- Social Science Unit, Zambart, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia, Africa
| | - Meroji Sebany
- Department of Global Health, Youth and Development, International Center for Research on Women, Washington DC, USA
| | - Constance Rs Mackworth-Young
- Social Science Unit, Zambart, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia, Africa.,Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC, United Kingdom
| | | | | | - Sue Clay
- 3C Regional Consultants, Lusaka, Zambia, Africa
| | - Kirsty Sievwright
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Virginia Bond
- Social Science Unit, Zambart, School of Public Health, University of Zambia, Ridgeway Campus, Lusaka, Zambia, Africa.,Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC, United Kingdom
| |
Collapse
|
7
|
Stangl AL, Sebany M, Kapungu C, Jessee C, Ricker CL, Chard E. Is HIV index testing and partner notification safe for adolescent girls and young women in low- and middle-income countries? J Int AIDS Soc 2020; 23 Suppl 5:e25562. [PMID: 32869478 PMCID: PMC7459168 DOI: 10.1002/jia2.25562] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/22/2020] [Accepted: 06/05/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION While HIV index testing and partner notification (PN) services have the potential to reach adolescent girls and young women (AGYW) aged 15 to 24 and their sexual partners in need of HIV testing services, the potential social harms have not yet been studied. This commentary highlights the risks of this approach, including intimate partner violence (IPV), stigma and discrimination, and outlines an urgent research agenda to fully understand the potential harms of PN for AGYW, calling for the development of mitigation strategies. DISCUSSION A substantial evidence base exists demonstrating the feasibility, acceptability and effectiveness of index testing and partner notification for adults aged 18 years and older in low- and middle-income countries (LMICs), particularly for men, and for adults who are married/cohabiting and referring a current sexual partner. AGYW who are most vulnerable to HIV infection in LMICs do not reflect these demographics. Instead, they are often in age-disparate partnerships, have limited negotiating power within relationships, experience high rates of violence and face economic challenges that necessitate transactional sex. PN services may be particularly difficult for adolescent girls under 18 who face restrictions on their decision making and are at increased risk of rape. Adolescent girls may also face coercion to notify partners due to unequal power dynamics in the provider-adolescent client relationship, as well as judgemental attitudes towards adolescent sexual activity among providers. CONCLUSIONS As index testing and PN with AGYW is already being rolled out in some LMICs, research is urgently needed to assess its feasibility and acceptability. Implementation science studies should assess the availability, accessibility, acceptability and quality of HIV PN services for AGYW. Qualitative studies and routine monitoring with age-disaggregated data are critical to capture potential social harms, PN preferences and support needs for AGYW aged 15 to 17, 18 to 20 and 21 to 24. To mitigate potential harms, PN methods should prioritize confidentiality and avoidance of adverse outcomes. Healthcare providers should be trained to conduct routine enquiry for IPV and provide first-line support. Support services for AGYW living with HIV and survivors of violence should be implemented alongside HIV PN.
Collapse
Affiliation(s)
- Anne L Stangl
- International Center for Research on WomenWashingtonDCUSA
- Hera SolutionsBaltimoreMDUSA
| | - Meroji Sebany
- International Center for Research on WomenWashingtonDCUSA
| | | | - Cassandra Jessee
- International Center for Research on WomenWashingtonDCUSA
- Making Cents InternationalWashingtonDCUSA
| | - Chelsea L Ricker
- International Center for Research on WomenWashingtonDCUSA
- Independent ConsultantWashingtonDCUSA
| | | |
Collapse
|
8
|
Mackworth-Young CRS, Bond V, Stangl AL, Chonta M, Wringe A. Coming of age with HIV: a temporal understanding of young women's experiences in Zambia. AIDS Care 2020; 33:159-166. [PMID: 31906703 DOI: 10.1080/09540121.2019.1709616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Young perinatally-infected women living with HIV in Zambia grew up alongside antiretroviral therapy (ART) roll-out and expanding prevention programmes. We used Bonnington's temporal framework to understand how HIV impacted the experiences of these women over time. Data were drawn from two sequential studies with a cohort of young women living with HIV: a qualitative study in 2014-16 and an ethnographic study in 2017-18. Data from workshops, in-depth interviews, participant observation and diaries were analysed thematically, guided by three temporalities within the framework: everyday, biographical and epochal time. In everyday time, repetitive daily treatment-taking reminded young women of their HIV status, affecting relationships and leading to secrecy with ART. In biographical time, past events including HIV disclosure, experiences of illness, and loss shaped present experiences and future aspirations. Lastly, in epochal time, the women's HIV infection and their survival were intimately interlinked with the history of ART availability. The epochal temporal understanding leads us to extend Reynolds Whyte's notion of "biogeneration" to conceptualise these women, whose experiences of living with HIV are enmeshed with their biosocial environment. Support groups for young women living with HIV should help them to process biographical events, as well as supporting their everyday needs.
Collapse
Affiliation(s)
- Constance R S Mackworth-Young
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Social Science Department, Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Virginia Bond
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Social Science Department, Zambart, School of Public Health, University of Zambia, Lusaka, Zambia
| | - Anne L Stangl
- International Center for Research on Women, Washington, DC, USA
| | | | - Alison Wringe
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
9
|
Stangl AL, Lilleston P, Mathema H, Pliakas T, Krishnaratne S, Sievwright K, Bell‐Mandla N, Vermaak R, Mainga T, Steinhaus M, Donnell D, Schaap A, Bock P, Ayles H, Hayes R, Hoddinott G, Bond V, Hargreaves JR. Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc 2019; 22:e25421. [PMID: 31840400 PMCID: PMC6912047 DOI: 10.1002/jia2.25421] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 10/23/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Integrating standardized measures of HIV stigma and discrimination into research studies of emerging HIV prevention approaches could enhance uptake and retention of these approaches, and care and treatment for people living with HIV (PLHIV), by informing stigma mitigation strategies. We sought to develop a succinct set of measures to capture key domains of stigma for use in research on HIV prevention technologies. METHODS From 2013 to 2015, we collected baseline data on HIV stigma from three populations (PLHIV (N = 4053), community members (N = 5782) and health workers (N = 1560)) in 21 study communities in South Africa and Zambia participating in the HPTN 071 (PopART) cluster-randomized trial. Forty questions were adapted from a harmonized set of measures developed in a consultative, global process. Informed by theory and factor analysis, we developed seven scales, with values ranging from 0 to 3, based on a 4-point agreement Likert, and calculated means to assess different aspects of stigma. Higher means reflected more stigma. We developed two measures capturing percentages of PLHIV who reported experiencing any stigma in communities or healthcare settings in the past 12 months. We validated our measures by examining reliability using Cronbach's alpha and comparing the distribution of responses across characteristics previously associated with HIV stigma. RESULTS Thirty-five questions ultimately contributed to seven scales and two experience measures. All scales demonstrated acceptable to very good internal consistency. Among PLHIV, a scale captured internalized stigma, and experience measures demonstrated that 22.0% of PLHIV experienced stigma in the community and 7.1% in healthcare settings. Three scales for community members assessed fear and judgement, perceived stigma in the community and perceived stigma in healthcare settings. Similarly, health worker scales assessed fear and judgement, perceived stigma in the community and perceived co-worker stigma in healthcare settings. A higher proportion of community members and health workers reported perceived stigma than the proportion of PLHIV who reported experiences of stigma. CONCLUSIONS We developed novel, valid measures that allowed for triangulation of HIV stigma across three populations in a large-scale study. Such comparisons will illuminate how stigma influences and is influenced by programmatic changes to HIV service delivery over time.
Collapse
Affiliation(s)
- Anne L Stangl
- International Center for Research on WomenWashingtonDCUSA
| | | | - Hlengani Mathema
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
- Division of Public Health Surveillance and ResponseNational Institute for Communicable DiseasesNational Health Laboratory ServiceJohannesburgSouth Africa
| | | | | | | | - Nomhle Bell‐Mandla
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Redwaan Vermaak
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Tila Mainga
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
| | - Mara Steinhaus
- International Center for Research on WomenWashingtonDCUSA
| | | | - Ab Schaap
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
| | - Peter Bock
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Helen Ayles
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
| | - Richard Hayes
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
| | - Graeme Hoddinott
- Desmond Tutu TB CentreDepartment of Paediatrics and Child HealthFaculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
| | - Virginia Bond
- London School of Hygiene and Tropical MedicineLondonUnited Kingdom
- ZambartSchool of MedicineUniversity of ZambiaLusakaZambia
| | | | | |
Collapse
|
10
|
Pantelic M, Sprague L, Stangl AL. It's not "all in your head": critical knowledge gaps on internalized HIV stigma and a call for integrating social and structural conceptualizations. BMC Infect Dis 2019; 19:210. [PMID: 30832613 PMCID: PMC6399894 DOI: 10.1186/s12879-019-3704-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/09/2019] [Indexed: 01/20/2023] Open
Abstract
Background Internalized HIV stigma is a public health concern as it can compromise HIV prevention, care and treatment. This paper has two aims. First, it highlights the urgent need for research evidence on internalized HIV stigma based on critical knowledge gaps. Here, critical knowledge gaps were identified based on most up-to-date systematic review-level evidence on internalized stigma related to HIV and mental health difficulties. Secondly, the paper calls for a shift in focus of internalized HIV stigma research, one that moves beyond psychological frameworks to integrate social, structural and intersectional conceptualizations of stigma. This part of the paper reviews the evolution of stigma theory since Goffman’s 1963 seminal work - which defined stigma - to present. Main text Despite studies consistently suggesting that internalized HIV stigma is more prevalent than enacted stigma, there is little evidence of well-established programs to address it. In addition to this, considerable gaps in basic knowledge about the drivers of internalized HIV stigma hamper the development of an evidence-based response to the problem. The limited intervention and epidemiological research on the topic treats internalized HIV stigma as a purely psychological phenomenon. The second part of the paper provides arguments for studying internalized HIV stigma as a function of social and structural forces: (1) Individual-level interventions for internalized HIV stigma are rooted in out-dated theoretical assumptions; (2) From an ethics point of view, it could be argued that individual-level interventions rely on a victim-centric approach to a public health problem; (3) Social and structural approaches to internalized HIV stigma must be explored due to the high opportunity cost associated with small-scale individual-level interventions. Conclusions Critical gaps in intervention and epidemiological research in internalized HIV stigma remain. There has been an absence of a shared, sound theoretical understanding of internalized HIV stigma as a manifestation of social and structural factors. This commentary sought to stimulate a dialogue to remedy this absence. Future research should take into account ethical considerations, the evolution of stigma theory over the past five decades, intersectionality and opportunity cost when framing hypotheses, developing theories of change and designing interventions.
Collapse
Affiliation(s)
- Marija Pantelic
- Frontline AIDS, Secretariat, Preece House, 91-101 Davigdor Rd, Brighton, Hove, BN3 1RE, UK. .,Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 -37 Wellington Square, Oxford, OX1 2ER, UK.
| | - Laurel Sprague
- Global Network of People Living with HIV (GNP+), Eerste Helmersstraat 17 B3 I, 1054 CX, Amsterdam, The Netherlands
| | - Anne L Stangl
- Department of Global Health, Youth and Development, The International Center for Research on Women, 1120 20th St. NW Suite 500N, Washington, DC, 20036, USA
| |
Collapse
|
11
|
Stangl AL, Singh D, Windle M, Sievwright K, Footer K, Iovita A, Mukasa S, Baral S. A systematic review of selected human rights programs to improve HIV-related outcomes from 2003 to 2015: what do we know? BMC Infect Dis 2019; 19:209. [PMID: 30832599 PMCID: PMC6399958 DOI: 10.1186/s12879-019-3692-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 01/08/2019] [Indexed: 01/05/2023] Open
Abstract
Background Repressive legal environments and widespread human rights violations act as structural impediments to efforts to engage key populations at risk of HIV infection in HIV prevention, care, and treatment efforts. The identification and scale-up of human rights programs and rights-based interventions that enable coverage of and retention in evidence-based HIV prevention and treatment approaches is crucial for halting the epidemic. Methods We conducted a systematic review of studies that assessed the effectiveness of human rights interventions on improving HIV-related outcomes between 1/1/2003–28/3/2015 per PRISMA guidelines. Studies of any design that sought to evaluate an intervention falling into one of the following UNAIDS’ key human rights program areas were included: HIV-related legal services; monitoring and reforming laws, policies, and regulations; legal literacy programs; sensitization of lawmakers and law enforcement agents; and training for health care providers on human rights and medical ethics related to HIV. Results Of 31,861 peer-reviewed articles and reports identified, 23 were included in our review representing 15 different populations across 11 countries. Most studies (83%) reported a positive influence of human rights interventions on HIV-related outcomes. The majority incorporated two or more principles of the human rights-based approach, typically non-discrimination and accountability, and sought to influence two or more elements of the right to health, namely availability and acceptability. Outcome measures varied considerably, making comparisons between studies difficult. Conclusion Our review revealed encouraging evidence of human rights interventions enabling a comprehensive HIV response, yet critical gaps remain. The development of a research framework with standardized indicators is needed to advance the field. Promising interventions should be implemented on a larger scale and rigorously evaluated. Funding for methodologically sound evaluations of human rights interventions should match the demand for human rights-based and structural approaches to protect those most vulnerable from HIV infection. Electronic supplementary material The online version of this article (10.1186/s12879-019-3692-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Anne L Stangl
- Department of Global Health, Youth and Development, International Center for Research on Women, 1120 20th St. NW Suite 500N, Washington, DC, 20036, USA.
| | - Devaki Singh
- Department of Global Health, Youth and Development, International Center for Research on Women, 1120 20th St. NW Suite 500N, Washington, DC, 20036, USA
| | - Michael Windle
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Kirsty Sievwright
- Department of Global Health, Youth and Development, International Center for Research on Women, 1120 20th St. NW Suite 500N, Washington, DC, 20036, USA
| | - Katherine Footer
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Alexandrina Iovita
- Human Rights Division, Joint United Nations Programme on HIV/AIDS, Geneva, Switzerland
| | - Stella Mukasa
- Department of Global Health, Youth and Development, International Center for Research on Women, 1120 20th St. NW Suite 500N, Washington, DC, 20036, USA
| | - Stefan Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| |
Collapse
|
12
|
Stangl AL, Earnshaw VA, Logie CH, van Brakel W, C Simbayi L, Barré I, Dovidio JF. The Health Stigma and Discrimination Framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med 2019; 17:31. [PMID: 30764826 PMCID: PMC6376797 DOI: 10.1186/s12916-019-1271-3] [Citation(s) in RCA: 518] [Impact Index Per Article: 103.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 01/23/2019] [Indexed: 12/18/2022] Open
Abstract
Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally. In order to halt the stigmatization process and mitigate the harmful consequences of health-related stigma (i.e. stigma associated with health conditions), it is critical to have an explicit theoretical framework to guide intervention development, measurement, research, and policy. Existing stigma frameworks typically focus on one health condition in isolation and often concentrate on the psychological pathways occurring among individuals. This tendency has encouraged a siloed approach to research on health-related stigmas, focusing on individuals, impeding both comparisons across stigmatized conditions and research on innovations to reduce health-related stigma and improve health outcomes. We propose the Health Stigma and Discrimination Framework, which is a global, crosscutting framework based on theory, research, and practice, and demonstrate its application to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV, and obesity/overweight. We also discuss how stigma related to race, gender, sexual orientation, class, and occupation intersects with health-related stigmas, and examine how the framework can be used to enhance research, programming, and policy efforts. Research and interventions inspired by a common framework will enable the field to identify similarities and differences in stigma processes across diseases and will amplify our collective ability to respond effectively and at-scale to a major driver of poor health outcomes globally.
Collapse
Affiliation(s)
- Anne L Stangl
- International Center for Research on Women, 1120 20th St. NW, Suite 500N, Washington, DC, 20036, USA.
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA
| | - Carmen H Logie
- Factor-Inwentash Faculty of Social Work, University of Toronto and Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | | | - Leickness C Simbayi
- Human Sciences Research Council & Department of Psychiatry & Mental Health, University of Cape Town, Cape Town, South Africa
| | - Iman Barré
- International Center for Research on Women, 1120 20th St. NW, Suite 500N, Washington, DC, 20036, USA
| | | |
Collapse
|
13
|
Footer K, Windle M, Ferguson L, Hatcher J, Lyons C, Gorin E, Stangl AL, Golub S, Gruskin S, Baral S. A Meta-Narrative Literature Synthesis and Framework to Guide Future Evaluation of Legal Empowerment Interventions. Health Hum Rights 2018; 20:65-84. [PMID: 30568403 PMCID: PMC6293352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Legal empowerment is increasingly recognized as a key approach for addressing socio-structural determinants of health and promoting the well-being and human rights of vulnerable populations. Legal empowerment seeks to increase people's capacity to understand and use the law. However, limited consensus remains on the effectiveness of legal empowerment interventions in optimizing health outcomes. Leveraging a meta-narrative approach, we synthesized literature describing how legal empowerment interventions have been operationalized and empirically studied with respect to health determinants. The studies included here document diverse legal empowerment approaches and highlight how interventions changed the context surrounding the health of vulnerable populations. The absence of robust conceptualization, operationalization, and measurement of the risk contexts in which legal empowerment approaches operate limits the clarity with which interventions' impact on health can be ascertained. Despite this, legal empowerment is a promising approach to address the health of marginalized populations. To foster support between the fields of legal empowerment and health, we explore the limitations in study design and measurement of the existing evidence base; such scrutiny could strengthen the rigor of future research. This paper provides a guide to the socio-structural levels across which legal empowerment interventions impact health outcomes in order to inform future interventions.
Collapse
Affiliation(s)
- Katherine Footer
- Assistant scientist in the Center for Public Health and Human Rights, Department of Epidemiology, Department of Health Behavior and Society, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Michael Windle
- Doctoral research assistant in the Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Laura Ferguson
- Director of Program on Global Health & Human Rights and Assistant Professor of Preventive Medicine, Department of Preventive Medicine, University of Southern California, Los, Angeles, CA, USA
| | - Jordan Hatcher
- Research assistant in the Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Carrie Lyons
- Senior research coordinator in the Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Emma Gorin
- Research assistant in the Department of International Health, Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Anne L. Stangl
- Senior behavioral scientist in the Department of Global Health, International Center for Research on Women, Washington, DC, USA
| | - Steven Golub
- Development consultant for the Guidance Committee of the Namati Global Legal Empowerment Network, Berkeley, CA, USA
| | - Sofia Gruskin
- Director of Institute on Inequalities in Global Health and Professor of Preventive Medicine, School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Stefan Baral
- Associate Professor in the Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
| |
Collapse
|
14
|
Mackworth-Young CR, Bond V, Wringe A, Konayuma K, Clay S, Chiiya C, Chonta M, Sievwright K, Stangl AL. "My mother told me that I should not": a qualitative study exploring the restrictions placed on adolescent girls living with HIV in Zambia. J Int AIDS Soc 2018; 20. [PMID: 29219248 PMCID: PMC5810345 DOI: 10.1002/jia2.25035] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 11/20/2017] [Indexed: 11/23/2022] Open
Abstract
Introduction Adolescent girls in sub‐Saharan Africa are disproportionately affected by HIV due to a range of social and structural factors. As they transition to adulthood, they are recipients of increasing blame for HIV infection and ‘improper’ sex, as well as increasing scrutiny, restrictions and surveillance. This study used a qualitative and participatory approach to explore the messaging and restrictions imposed on adolescent girls living with HIV in Zambia. Methods Thirty‐four in‐depth interviews and four participatory workshops were carried out with 24 adolescent girls aged 15 to 19 years old living with HIV in Lusaka, Zambia. Key themes explored included experiences living with HIV, finding out about HIV status, disclosure, experiences with antiretroviral treatment, and support needs. Data were organized, coded and analysed using a grounded theory approach to thematic analysis. This analysis uses data on participants’ experiences of living with HIV and their interactions with their parents, guardians and healthcare providers. Results Family and healthcare providers, partly in a quest to protect both the health of adolescent girls living with HIV and also to protect them from blaming discourse, imposed restrictions on their behaviour around three main topics: don't disclose your HIV status, don't have sex, and don't miss your medicines. These restrictions were often delivered using tactics of fear, and usually disconnected from other options. Participants responded to these messages in several ways, including internalizing the messages, changing their behaviour either to comply with or resist the restrictions, by remaining silent and anxious when restrictions were broken, and developing concerns around their own health and sexual and reproductive aspirations. Participants also sometimes experiencing stigma when restrictions could not be maintained. Conclusions Restrictive messages were delivered to adolescent girls living with HIV through the broader social discourses of stigma, religion, and global and local narratives about HIV. Programmes aiming to support adolescent girls living with HIV need to work together with parents and healthcare providers to reflect on the impact of sanctioning messages, and to encourage more enabling and empowering messaging for adolescent girls living with HIV.
Collapse
Affiliation(s)
- Constance Rs Mackworth-Young
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Social Science Department, Zambart, Lusaka, Zambia
| | - Virginia Bond
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Social Science Department, Zambart, Lusaka, Zambia
| | - Alison Wringe
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Sue Clay
- 3Cs Regional Consultants, Lusaka, Zambia
| | | | | | | | - Anne L Stangl
- International Center for Research on Women, Washington, DC, USA
| |
Collapse
|
15
|
Stahlman S, Hargreaves JR, Sprague L, Stangl AL, Baral SD. Measuring Sexual Behavior Stigma to Inform Effective HIV Prevention and Treatment Programs for Key Populations. JMIR Public Health Surveill 2017; 3:e23. [PMID: 28446420 PMCID: PMC5425775 DOI: 10.2196/publichealth.7334] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 02/26/2017] [Accepted: 03/01/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The levels of coverage of human immunodeficiency virus (HIV) treatment and prevention services needed to change the trajectory of the HIV epidemic among key populations, including gay men and other men who have sex with men (MSM) and sex workers, have consistently been shown to be limited by stigma. OBJECTIVE The aim of this study was to propose an agenda for the goals and approaches of a sexual behavior stigma surveillance effort for key populations, with a focus on collecting surveillance data from 4 groups: (1) members of key population groups themselves (regardless of HIV status), (2) people living with HIV (PLHIV) who are also members of key populations, (3) members of nonkey populations, and (4) health workers. METHODS We discuss strengths and weaknesses of measuring multiple different types of stigma including perceived, anticipated, experienced, perpetrated, internalized, and intersecting stigma as measured among key populations themselves, as well as attitudes or beliefs about key populations as measured among other groups. RESULTS With the increasing recognition of the importance of stigma, consistent and validated stigma metrics for key populations are needed to monitor trends and guide immediate action. Evidence-based stigma interventions may ultimately be the key to overcoming the barriers to coverage and retention in life-saving antiretroviral-based HIV prevention and treatment programs for key populations. CONCLUSIONS Moving forward necessitates the integration of validated stigma scales in routine HIV surveillance efforts, as well as HIV epidemiologic and intervention studies focused on key populations, as a means of tracking progress toward a more efficient and impactful HIV response.
Collapse
Affiliation(s)
- Shauna Stahlman
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, United States
| | - James R Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Laurel Sprague
- HIV Justice Network, Detroit, MI, United States.,Irvin D Reid Honors College, Wayne State University, Detroit, MI, United States
| | - Anne L Stangl
- Department of Global Health, Youth and Development, International Center for Research on Women, Washington, DC, United States
| | - Stefan D Baral
- Center for Public Health and Human Rights, Department of Epidemiology, Johns Hopkins University, Baltimore, MD, United States
| |
Collapse
|
16
|
Nayar US, Stangl AL, De Zalduondo B, Brady LM. Reducing stigma and discrimination to improve child health and survival in low- and middle-income countries: promising approaches and implications for future research. J Health Commun 2014; 19 Suppl 1:142-63. [PMID: 25207451 PMCID: PMC4205916 DOI: 10.1080/10810730.2014.930213] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The social processes of stigmatization and discrimination can have complex and devastating effects on the health and welfare of families and communities, and thus on the environments in which children live and grow. The authors conducted a literature review to identify interventions for reducing the stigma and discrimination that impede child health and well-being in low- and middle-income countries, with a focus on nutrition, HIV/AIDS, neonatal survival and infant health, and early child development. Despite broad consensus on the importance of stigma and discrimination as barriers to access and uptake of health information and services, the authors found a dearth of research and program evaluations directly assessing effective interventions in the area of child health except in the area of reducing HIV-related stigma and discrimination. While the literature demonstrates that poverty and social exclusion are often stigma-laden and impede adult access to health information and services, and to education relevant to family planning, child rearing, nutrition, health promotion, and disease prevention, the child health literature does not document direct connections between these known mediators of child health and the stigmatization of either children or their caregivers. The child health field would greatly benefit from more research to understand and address stigma as it relates to child health and well-being. The authors suggest applying a framework, adapted from the HIV stigma field, to direct future research and the adaptation of existing strategies to reduce HIV-related stigma and discrimination to address social and health-related stigmas affecting children and their families.
Collapse
Affiliation(s)
| | - Anne L. Stangl
- International Center for Research on Women
,
Washington
,
District of Columbia
,
USA
| | | | - Laura M. Brady
- International Center for Research on Women
,
Washington
,
District of Columbia
,
USA
| |
Collapse
|
17
|
Stangl AL, Lloyd JK, Brady LM, Holland CE, Baral S. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? J Int AIDS Soc 2013; 16:18734. [PMID: 24242268 PMCID: PMC3833106 DOI: 10.7448/ias.16.3.18734] [Citation(s) in RCA: 446] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 08/23/2013] [Accepted: 08/29/2013] [Indexed: 01/30/2023] Open
Abstract
INTRODUCTION HIV-related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response. METHODS We conducted a systematic review of studies and reports that assessed the effectiveness of interventions to reduce HIV stigma and discrimination between 1 January 2002 and 1 March 2013. Databases searched for peer-reviewed articles included PubMed, Scopus, EBSCO Host -CINAHL Plus, Psycinfo, Ovid, Sociofile and Popline. Reports were obtained from the www.HIVAIDSClearinghouse.eu, USAID Development Experience Clearinghouse, UNESCO HIV and AIDS Education Clearinghouse, Google, WHO and UNAIDS. Ancestry searches for articles included in the systematic review were also conducted. Studies of any design that sought to reduce stigma as a primary or secondary objective and included pre- and post-intervention measures of stigma were included. RESULTS Of 2368 peer-reviewed articles and reports identified, 48 were included in our review representing 14 different target populations in 28 countries. The majority of interventions utilized two or more strategies to reduce stigma and discrimination, and ten included structural or biomedical components. However, most interventions targeted a single socio-ecological level and a single domain of stigma. Outcome measures lacked uniformity and validity, making both interpretation and comparison of study results difficult. While the majority of studies were effective at reducing the aspects of stigma they measured, none assessed the influence of stigma or discrimination reduction on HIV-related health outcomes. CONCLUSIONS Our review revealed considerable progress in the stigma-reduction field. However, critical challenges and gaps remain which are impeding the identification of effective stigma-reduction strategies that can be implemented by national governments on a larger scale. The development, validation, and consistent use of globally relevant scales of stigma and discrimination are a critical next step for advancing the field of research in this area. Studies comparing the effectiveness of different stigma-reduction strategies and studies assessing the influence of stigma reduction on key behavioural and biomedical outcomes are also needed to maximize biomedical prevention efforts.
Collapse
Affiliation(s)
- Anne L Stangl
- Department of Global Health, International Center for Research on Women, Washington, DC, USA;
| | | | | | | | | |
Collapse
|
18
|
Stangl AL, Bunnell R, Wamai N, Masaba H, Mermin J. Measuring quality of life in rural Uganda: reliability and validity of summary scores from the medical outcomes study HIV health survey (MOS-HIV). Qual Life Res 2011; 21:1655-63. [PMID: 22198741 DOI: 10.1007/s11136-011-0075-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Summary scores derived from the medical outcomes study HIV health survey (MOS-HIV) are used to assess treatment impacts among HIV-infected patients in Western settings, but have yet to be validated in rural, African settings. We examined the reliability, validity and responsiveness of scores among a prospective cohort of 947 HIV-1-infected adults initiating antiretroviral therapy between May 2003 and May 2004 in rural Uganda. METHODS Physical (PHS) and mental health (MHS) summary scores were developed from baseline MOS-HIV sub-domains using exploratory factor analysis. Construct and discriminant validity were established by comparing mean summary scores across known groups of sociodemographic, clinical and health status characteristics. Effect sizes were calculated to assess responsiveness to therapy. RESULTS Reliability of the PHS and MHS scores was 0.79 and 0.85, respectively. Mean baseline PHS and MHS scores varied significantly by CD4 cell count, HIV viral load, WHO stage of disease and Karnofsky performance status scores. By 12 months on antiretroviral therapy, PHS and MHS scores improved by 14.6 points (P < 0.001) and 13.9 points (P < 0.001), respectively. CONCLUSIONS PHS and MHS scores can be derived from the MOS-HIV and used to assess health status among cohorts of patients taking antiretroviral therapy in rural Uganda.
Collapse
Affiliation(s)
- Anne L Stangl
- The Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA.
| | | | | | | | | |
Collapse
|
19
|
Batamwita R, Moore DM, King R, Mills E, Stangl AL. Assessment of antiretroviral therapy knowledge and willingness of persons with HIV to support its uptake in Uganda. Patient Prefer Adherence 2011; 5:499-506. [PMID: 22114463 PMCID: PMC3218110 DOI: 10.2147/ppa.s23289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Access to care and treatment services for human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) are hampered by human resource constraints and knowledge gaps about antiretroviral therapy. Training people with HIV/AIDS (PWA) as educators on antiretroviral therapy may help in the expansion of antiretroviral therapy-related knowledge in Africa. The aim of this study was to assess the antiretroviral therapy-specific knowledge, beliefs, and attitudes of PWA as well as their proactive communication with community members and to explore their willingness to serve as support personnel. METHODS Data were obtained from a large randomized trial of PWA. We analyzed qualitative and quantitative data from 524 PWA aged 18 years and over who initiated home-based antiretroviral therapy in 2003. We assessed knowledge and communication of HIV prevention and treatment messages by PWA to communities using structured messages complemented with other knowledge questions and the willingness of PWA to serve as support persons. Descriptive bivariate associations and logistic regression statistical methods were performed. In addition, qualitative data analysis was used. RESULTS The level of knowledge about antiretroviral therapy was high among all PWA on several technical attributes. Overall, 90% of PWA reported that they had been consulted by community members for informed opinions on antiretroviral therapy, 70% felt they were opinion leaders on aspects of antiretroviral therapy within the communities, and approximately 70% were willing to be engaged as community support persons. Those who were classified as opinion leaders reported being approached more regularly by community members for expert advice about antiretroviral therapy compared with nonopinion leaders (odds ratio [OR] 11.7; 95% confidence interval [CI] 7.3-18.6), and opinion leaders were significantly more informed on most technical attributes of antiretroviral therapy, such as "who qualifies for antiretroviral therapy based on CD4 count" (OR 1.6, 95% CI 1.1-2.0) and "the need to be evaluated for antiretroviral therapy" (OR 1.8, 95% CI 1.2-2.0). CONCLUSION Opinion leaders demonstrated correct knowledge and willingness to provide information on antiretroviral therapy care and treatment issues and were, in turn, consulted more frequently for antiretroviral therapy advice compared with nonopinion leaders. Training opinion leaders to work as community support personnel may increase knowledge about antiretroviral therapy in underserved communities.
Collapse
Affiliation(s)
| | - David M Moore
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, Canada
| | | | | | - Anne L Stangl
- International Center for Research on Women, Washington, DC, USA
| |
Collapse
|
20
|
Stangl AL, Wamai N, Mermin J, Awor AC, Bunnell RE. Trends and predictors of quality of life among HIV-infected adults taking highly active antiretroviral therapy in rural Uganda. AIDS Care 2007; 19:626-36. [PMID: 17505923 DOI: 10.1080/09540120701203915] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We examined trends and predictors of quality of life (QOL) over 12 months among a prospective cohort of 947 HIV-1-infected adults initiating highly active antiretroviral therapy (HAART) between May 2003 and May 2004 in rural Uganda. Participants provided clinical, demographic and psychosocial data at baseline and every three months thereafter. Outcome measures included physical and mental health summary scores based on the Medical Outcomes Study-HIV Health Survey (MOS-HIV). Generalised estimating equations were used to assess magnitude of change in summary scores and factors associated with QOL. Of 710 women and 237 men enrolled, the mean age was 38.7 years and mean baseline CD4 cell count was 124.1 cells/microL. At enrollment, physical and mental health summary scores were 39.2 and 40, respectively. By 12 months of HAART, scores increased by 11.2 points (p <0.001) and 7.4 points (p <0.001), respectively. For both scores, most gains were achieved by the third month of therapy. While several clinical, psychosocial and sociodemographic factors predicted QOL at HAART initiation, financial dependence on others was the only remaining predictor after controlling for time on HAART. Interventions to enhance the economic and employment opportunities of patients taking HAART in rural Africa may help maximise gains in QOL.
Collapse
Affiliation(s)
- A L Stangl
- Department of International Health and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA 70112-2715, USA.
| | | | | | | | | |
Collapse
|