HIV Inequities, the Therapeutic Alliance, Moral Injury, and Burnout: A Call for Nurse Workforce Participation and Action.

ABSTRACT: Health inequities for those living with HIV have persisted for key populations in the United States and globally. To address these inequities, in accordance with Goals 2 and 3 of the National HIV/AIDS Strategy for the United States, the evidence indicates that the therapeutic alliance could be effective in addressing impediments that undermine HIV outcomes. Nonetheless, the therapeutic alliance relies on health care providers, particularly nurses, reporting burnout and moral injury, further exacerbated by COVID-19. Burnout and moral injury have forced the systemic undervaluing of nurses as a social-cultural norm to the fore-in part a legacy of the economic model that underpins the health care system. Given a looming health workforce shortage and negative effects for key populations with HIV already experiencing health inequities, historic opportunities now exist to advance national institutional reforms to support nurses and other health professionals. This opportunity calls for concerted attention, multisectoral dialogue, and action, with nurses participating in and leading policy and interventions.

Vaccine Inequities and the Legacies of Colonialism: Speculative Fiction's Challenge to Medicine.

New vaccines to prevent COVID-19 and malaria underscore the importance of scientific advances to promote public health globally. How is credit for such scientific discoveries attributed, and who benefits? The complex narrative of Amitav Ghosh's The Calcutta Chromosome, both historical and speculative, demonstrates how medicine has come to value particular kinds of advances over others, prompting readers to question who controls access to resources and at what cost to global populations. In Ghosh's imagined world, scientific discovery is evaluated and rewarded-and ultimately deemed necessary-for its ability to serve communal, public health needs.

When Social and Personal Norms Collide: Narratives of South African Women Navigating Transactional Sexual Relationships with Blessers.

Due to the negative implications of transactional sexual relationships (TSRs) for women's sexual and reproductive health, studies of social norms in sub-Saharan and South Africa have sought to inform HIV-related risk and interventions in this key population. To date, however, little research has investigated the normative conflicts facing women in African settings when initiating, continuing or abstaining from participation in TSRs. In 2017-2018, we investigated conflicts black South African women in KwaZulu-Natal expressed between adhering to social versus personal norms in TSRs with "blessers"-wealthy men who gift women financially or materially-typically in exchange for sex. Participants expressed conflicts between social norms of blesser engagement to satisfy aspirations for money/material items vs. personal norms of retaining virginity and fidelity to partners. Women largely ignored adverse sexual health risks of HIV and unintended pregnancy. Participants highlighted internal conflicts, prompting reflection on their desires, choices and normative behaviors, also informing women's self-concept, self-efficacy and desires for relationship satisfaction. Greater reflection from women about personal norms and values-and attention to their self-efficacy in relationships-may assist in understanding and advancing women's holistic health and wellbeing in research and interventions among this population and potentially women in other settings.

What Matters Most? The Power of Kafka's Metamorphosis to Advance Understandings of HIV Stigma and Inform Empathy in Medical Health Education.

HIV stigma, a social-medical problem, continues to confound researchers and health professionals, while undermining outcomes. Empathy may reduce stigma; its absence may predict stigma. This research investigates: How does Kafka's Metamorphosis advance understandings of HIV stigma in medical health education? Metamorphosis amplifies the sociological-relational mechanisms fostering HIV stigma. It offers a multi-disciplinary, responsive space for ethical, humanistic and clinical inquiry to meet: enabling students to consider how social structures shape health inequities, moral, social experience, and their professional identity within. Metamorphosis may ultimately promote medical health humanities' social mission-allowing literature to unfold such revelations towards greater equity in health.

Understanding perinatal mental illness as a governance concern in South Africa through health provider perspectives.

Women in South Africa experience a disproportionately high prevalence of common perinatal mental disorders (CPMDs). These disorders often remain a silent burden and a complex health, social, and policy concern, both nationally and globally. Moreover, policy efforts to address this concern have been fragmented. Greater understanding of the governance of perinatal mental illness is needed to address this complex issue. No research to date has focused explicitly on the importance of 'issue framing' to advance governance for perinatal mental health. We sought to achieve a more nuanced understanding of clinical governance and issue framing for perinatal mental health in South Africa by interviewing 24 key informants with expertise in perinatal mental illness. Dominant themes encompassed: framing of perinatal mental health determines its priority; perinatal mental health is not prioritised due to competition from other health concerns; and, screening policy responses are shaped by the framing. We found that understanding the varying views influencing perinatal mental illness provides insights into how experts frame the problem. Findings suggest that a better understanding of policy implementation and responses in South Africa is important in guiding research, policy, and practice, while improving the governance of perinatal mental illness.

'Eventually I wanted something more': sexual self-reflections of South African women engaged in transactional sexual relationships with blessers.

The term 'blesser' emerged from social media in South Africa, typically denoting an older man who provides a younger woman with money and/or luxury items in exchange for sex. Within an increasingly consumerist culture, such transactional sexual relationships hold powerful appeal, and remain highly prevalent. An estimated one in three Black South African women have engaged in transactional sex. While these liaisons are associated with negative health outcomes for women, especially in high HIV prevalence settings, attention to how they affect Black women's sexuality is under-studied-especially with respect to emotional and sexual development-an important part of sexual rights and wellbeing. We used qualitative methods to investigate 22 women's experiences with blessers. A sexual rights framework was utilised to explore human rights dimensions. We found women's rights to engage in consensual sex, pursue sexual pleasure and ensure their bodily integrity were compromised. Many participants recognised the psychological costs and limitations of engaging in blesser relationships. Women communicated that they realised such partnerships failed to meet their emotional and relationship needs. Against the backdrop of structural gender inequality, Black South African women's narratives should inform research, programmes and educational interventions aimed at advancing women's sexual development, rights and wellbeing.

Health care providers' perceptions of barriers to perinatal mental healthcare in South Africa.

BACKGROUND: Perinatal mental disorders are a leading contributor to morbidity and mortality during pregnancy and postpartum, and are highly treatable when identified early. However, many women, especially in low and middle-income countries, lack access to routine identification and treatment of mental illness in public health settings. The prevalence of perinatal depression and anxiety disorders, common mental disorders, is three times higher for South African women relative to women in high-income countries. The public health system has begun to integrate mental health into maternal care, making South Africa a relevant case study of perinatal mental healthcare. Yet studies are few. We sought to investigate healthcare providers' perceptions of the barriers to early identification and screening of common perinatal mental disorders in public health facilities in South Africa. METHODS: Employing qualitative methods, we used purposive sampling to identify study participants, supplemented by snowball sampling. From September 2019-June 2020, we conducted in-depth interviews with 24 key informants in South Africa. All interviews were recorded and transcribed verbatim. We used a thematic approach to generate initial analytical themes and then conducted iterative coding to refine them. We adapted a delivery systems' framework to organise the findings, depicted in a conceptual map. RESULTS: Reported barriers to early identification and treatment of mental illness in the perinatal period encompassed four levels: (1) structural factors related to policies, systems and resources; (2) socio-cultural factors, including language and cultural barriers; (3) organisational factors, such as lack of provider preparation and training and overburdened clinics; and (4) individual patient and healthcare provider factors. CONCLUSION: Barriers act across multiple levels to reduce quality mental health promotion and care, thereby creating an environment where inequitable access to identification of mental disorders and quality mental health services was embedded into systems and everyday practice. Integrated interventions across multiple levels are essential to improve the early identification and treatment of mental illness in perinatal women in South Africa. We provide recommendations derived from our findings to overcome barriers at each of the four identified levels.

Experience of religion and spirituality among socially marginalised people living with HIV in Mississippi.

African Americans in Mississippi have the highest HIV-related mortality and poverty rates in the USA, and they tend to be religious. Attitudes toward gender and sexuality are changing, yet few studies have investigated religion and spirituality among special populations living with HIV. Using grounded theory and qualitative methods, we investigated the experience of health and illness of a low-income, socially marginalised population living with HIV in two locations of Mississippi in 2015. In a context of high stigma and HIV-related health disparities, individuals turned, or returned, to religion, church and spirituality as sources of community and strength, which also motivated safer health behaviours. Findings underscore how religion and spirituality are enabling social determinants of health that are under-explored, untapped, potentially culturally acceptable, sustainable interventions at the community-level. We posit, given diminished funding for community-based services, the most significant influence churches could exert is in decreasing HIV stigma. Given the current US plan to end HIV by 2030, with appropriate stakeholder participation, the role of religion, spirituality and clergy could be further amplified via linkage to care providers and the 'normalisation' of the HIV discourse, to address disparities and improve the health of African Americans.

Enhancing agency for health providers and pregnant women experiencing intimate partner violence in South Africa.

Global policy frameworks call for strengthening the role of health systems to address intimate partner violence (IPV) and support women's agency, yet the evidence of health system responses remains slender in low- and middle-income countries (LMICs). In South Africa, 25-35% of pregnant women experience IPV, posing long-term health risks. We utilised agency as a theoretical construct, applying qualitative methods to investigate health professionals' experiences of a randomised controlled trial intervention to address IPV in pregnant women in five antenatal clinics (ANC) in Johannesburg (2011-2016). In-depth interviews (n = 16) were supplemented by participant observation, debriefing and field notes. Health providers viewed the intervention as enhancing health promotion agency and advancing help-seeking agency for IPV-exposed patients. Intervention nurses reported their own self-efficacy improved, and their relational and collective agency expanded. On-going supervision, mentorship and feedback were essential to establish the knowledge and skill-building necessary for providers to improve self-efficacy in intervention delivery. Integrating mental health services into primary ANC services is recommended. Findings offer insight into the untapped potential for LMIC health settings to become transformative, gender-responsive social systems, for patients and health professionals, in ways that advance women's agency, health, human rights and SDGs.

Towards ending the US HIV epidemic by 2030: Understanding social determinants of health and HIV in Mississippi.

The disproportionate burden of HIV-related inequities borne by African Americans in the US South amplifies the role of social determinants of health (SDH) in shaping social patterning of illness. Despite some attention, SDH remain overlooked in a biomedically oriented, federal HIV policy. Mississippi is the poorest state with the worst HIV outcomes, nationally. Using qualitative methods, we investigated how primarily African American, HIV-positive Mississippians experienced SDH and health inequities in their daily lives. Employing grounded theory and in-depth interviews (n = 25) in an urban and rural site in 2015 yielded these findings: (1) absence of an enabling structural environment; (a) HIV-stigma constructed via social discourse; (b) lack of psycho-social support and HIV education; (c) insufficient economic and social support resources; and (2) presence of family support for coping. Due to stigma, being HIV-positive seemed to lead to further status loss; diminished social position; reduced life chances; and contractions in particular freedoms. Stigma further compounded existing inequalities - contributing to the moral, social experience of those living with HIV. Trump's plan to end HIV by 2030 creates the opportunity to rethink the biomedical-paradigm and fully engage SDH - using social science theory and methods that address multi-level social determinants in ways that are also policy-responsive.

A Right-to-Health Lens on Perinatal Mental Health Care in South Africa.

South African women experience some of the highest rates of depression and anxiety globally. Despite South Africa's laudable human rights commitments to mental health in law, perinatal women are at high risk of common mental disorders due to socioeconomic factors, and they may lack access to mental health services. We used a right to mental health framework, paired with qualitative methods, to investigate barriers to accessing perinatal mental health care. Based on in-depth interviews with 14 key informants in South Africa, we found that (1) physical health was prioritized over mental health at the clinic level; (2) there were insufficient numbers of antenatal and mental health providers to ensure minimum essential levels of perinatal mental health services; (3) the implementation of human rights-based mental health policy has been inadequate; (4) the social determinants were absent from the clinic-level approach to mental health; and (5) a lack of context-specific provider training and support has undermined the quality of mental health promotion and care. We offer recommendations to address these barriers and improve approaches to perinatal mental health screening and care, guided by the following elements of the right to mental health: progressive realization; availability and accessibility; and acceptability and quality.

A randomized controlled pilot trial of a smoking cessation intervention for US women living with HIV: telephone-based video call vs voice call.

BACKGROUND: People living with HIV smoke at a rate three times that of the general population. This randomized controlled pilot trial tested the feasibility and acceptability of a video-call smoking cessation intervention in women living with HIV and its preliminary efficacy compared with a voice-call smoking cessation intervention. The study focused on women due to a paucity of studies among this population, and women are less likely than men to quit smoking when provided with conventional treatment. METHODS: Participants in both arms received an HIV-tailored smoking cessation intervention comprising eight 30-minute weekly counseling sessions in conjunction with active nicotine patches for 8 weeks. The only difference between the two arms was the delivery mode of the intervention: via either telephone-based video or voice call. Survival analysis and a Cox proportional hazard regression model were performed to identify factors predicting 6-month prolonged abstinence from smoking. RESULTS: A video-call intervention was almost 30% less feasible than a voice-call intervention because women in their 50s and 60s or poorer women living in some southern states did not have access to video-call equipment. However, those who received the video-call intervention were more likely to complete the study than those who had the voice-call intervention. There was no difference in the acceptability of the two interventions. A survival analysis revealed that those in the video arm were significantly more likely to maintain smoking abstinence over the 6-month follow-up period than those in the voice arm (log rank χ 2=4.02, P<0.05). CONCLUSION: Although a video-call intervention is less feasible than a voice-call intervention, the former seems to outperform the latter in achieving long-term smoking abstinence for women living with HIV, which may offer an advantage over establishing therapeutic alliance and visually monitoring their adherence to nicotine patches. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT02898597.

Unmet Mental Health and Social Service Needs of Formerly Incarcerated Women Living with HIV in the Deep South.

Due to the disproportionate burden of HIV among incarcerated women in the United States, jails and prisons have been identified as key sites for health service delivery. Recidivism remains high, potentially reflecting unmet mental health and social service needs of incarcerated women, especially during the postrelease adjustment period. However, little published research has investigated this possibility directly. We conducted semi-structured, in-depth interviews with previously incarcerated women living with HIV, and other key informants, and completed service-availability mapping in two Alabama cities. Key findings were: (a) discharge planning and postrelease support services to manage risky environments were absent, (b) postrelease services were concentrated in a few community-based organizations, (c) mental health and substance abuse treatment during re-entry was essential to prevent relapse, and (d) social support was crucial for postrelease adjustment. We propose a novel conceptual model with key steps to establish continuous care for previously incarcerated women living with HIV.

Qualitative Research Methods to Advance Research on Health Inequities Among Previously Incarcerated Women Living With HIV in Alabama.

Justice-involved HIV-positive women have poor health outcomes that constitute health inequities. Researchers have yet to embrace the range of qualitative methods to elucidate how psychosocial histories are connected to pathways of vulnerability to HIV and incarceration for this key population. We used life course narratives and intersubjectivity-predicated on interview dialogue-to investigate how familial and social settings established their social patterning of HIV, incarceration risk, and poor health. Working with two Alabama community-based organizations, we recruited and interviewed 24 HIV-positive cisgender women with cyclical incarceration. We analyzed the data by charting women's life histories and conducting iterative content analyses. Participants described chaotic home environments, marked by exposure to trauma in childhood. The majority experienced repeated sexual and physical abuse that went undiagnosed and untreated until adulthood. Adolescence and young adulthood were characterized by onset of substance use, violent intimate partnerships, and subsequent behavioral and mental health problems. In adulthood, risk behaviors persisted for decades and women lacked mental health treatment and social support. Life course narratives and intersubjectivity contributed to knowledge by affording agency to marginalized participants to reflect on and narrate their life stories; instilling needed trust for researchers to investigate the complex risk pathways and psychosocial histories with this population; illuminating the nature, timing, sequence, and frequency of events underlying women's vulnerability and exposure to HIV and incarceration; and clarifying that early shaping events in childhood are connected to later risk environments and behaviors in adolescence and adulthood, suggesting the need for earlier interventions than are typically proposed.

Analysing local-level responses to migration and urban health in Hillbrow: the Johannesburg Migrant Health Forum.

Johannesburg is home to a diverse migrant population and a range of urban health challenges. Locally informed and implemented responses to migration and health that are sensitive to the particular needs of diverse migrant groups are urgently required. In the absence of a coordinated response to migration and health in the city, the Johannesburg Migrant Health Forum (MHF) - an unfunded informal working group of civil society actors - was established in 2008. We assess the impact, contributions and challenges of the MHF on the development of local-level responses to migration and urban health in Johannesburg to date. In this Commentary, we draw on data from participant observation in MHF meetings and activities, a review of core MHF documents, and semi-structured interviews conducted with 15 MHF members.The MHF is contributing to the development of local-level migration and health responses in Johannesburg in three key ways: (1) tracking poor quality or denial of public services to migrants; (2) diverse organisational membership linking the policy process with community experiences; and (3) improving service delivery to migrant clients through participation of diverse service providers and civil society organisations in the Forum. Our findings indicate that the MHF has a vital role to play in supporting the development of appropriate local responses to migration and health in a context of continued - and increasing - migration, and against the backdrop of rising anti-immigrant sentiments.

Southern Women at Risk: Narratives of Familial and Social HIV Risk in Justice-Involved U.S. Women in Alabama.

Justice-involved HIV-positive women, particularly those in the U.S. South, are a hidden, understudied population. Little work has explored their psychosocial histories in relation to their HIV risk. We conducted a content analysis of their life history narratives from childhood to present, via in-depth interviews with 24 such women in 2 Alabama cities. Findings included the following: (a) In childhood/adolescence, consistent HIV risk factors were present, beginning with early sexual abuse and induction into alcohol/substance use; (b) By early adulthood, HIV and incarceration risks were compounded in social settings, through cyclical substance use, revictimization, and reoffending;

How Nurses in Johannesburg Address Intimate Partner Violence in Female Patients: Understanding IPV Responses in Low- and Middle-Income Country Health Systems.

One in three women, globally, experiences intimate partner violence (IPV). Although 80% of the world's population resides in the low- and middle-income countries (LMICs), health system responses to IPV are poorly understood. In 2013, the World Health Organization released new guidelines for IPV but universal screening was not recommended in LMICs due to perceived lack of capacity and insufficient evidence. South Africa, with IPV prevalence estimated at 31% to 55%, offers a window into LMIC health systems. South African women seek health care for partner abuse, yet no guidelines exist to direct providers. This research aimed to understand how and why nurses respond to IPV. Using a descriptive design, 25 nurses from five health facilities were interviewed, generating rich narratives of provider actions. Themes were coded and analyzed. An iterative process of constant comparison of emergent data was undertaken to verify and confirm final themes. In the absence of IPV guidelines, nurses employed interventions characterized as counseling, ascertaining abuse, and referral. Nurses' actions were motivated by fear for patients' survival, perceived professional obligations, patients' expectations of receiving treatment, personal experiences of IPV, and weak police responses to IPV. Findings indicated nurses were responding to IPV in a routine manner, yet comprehensive guidelines remain essential to govern and locate their actions within the framework of a public health response. South Africa yields lessons for enhancing understanding of IPV responses in LMICs, while contributing to a slim evidence base of the "how" and "why" of provider actions toward IPV in patients.

The HIV Prison Paradox: Agency and HIV-Positive Women's Experiences in Jail and Prison in Alabama.

Incarcerated women face significant barriers to achieve continuous HIV care. We employed a descriptive, exploratory design using qualitative methods and the theoretical construct of agency to investigate participants' self-reported experiences accessing HIV services in jail, in prison, and post-release in two Alabama cities. During January 2014, we conducted in-depth interviews with 25 formerly incarcerated HIV-positive women. Two researchers completed independent coding, producing preliminary codes from transcripts using content analysis. Themes were developed iteratively, verified, and refined. They encompassed (a) special rules for HIV-positive women: isolation, segregation, insults, food rationing, and forced disclosure; (b) absence of counseling following initial HIV diagnosis; and (c) HIV treatment impediments: delays, interruption, and denial. Participants deployed agentic strategies of accommodation, resistance, and care-seeking to navigate the social world of prison and HIV services. Findings illuminate the "HIV prison paradox": the chief opportunities that remain unexploited to engage and re-engage justice-involved women in the HIV care continuum.

Neglected Population, Neglected Right: Children Living with HIV and the Right to Science.

The laws, language, and tools of human rights have been instrumental in expanding access to lifesaving treatment for people living with HIV. Children, however, remain a neglected population, as evidenced by inadequate child-specific and child-friendly HIV treatment options. In this article, we explore the right to science, a potentially powerful but underdeveloped right in international law, and its application to research and development for pediatric HIV treatment. Drawing on reports of human rights bodies and scholars and applying the human rights typology of state obligations to respect, protect, and fulfill, we argue that states have five core obligations related to research and development for child-specific and child-friendly treatment: (1) adopting a public goods approach to science and science policy; (2) including and protecting children in research activities; (3) adopting legal and policy frameworks to support research and development through public funding and private sector incentives; (4) promoting international cooperation and assistance; and (5) ensuring the participation of marginalized communities in decision-making processes. In concluding, we make a number of recommendations for states, human rights bodies, international organizations, civil society, and private industry to further develop and implement the right to science.