Stigmatizing clinical setting erodes physician-patient interaction quality for sexual minority men through perceived HIV stigma and HIV infection concerns in Zambia.

This study investigated whether perceived HIV stigma and HIV infection concerns among healthcare providers (HCPs) mediate the association between stigmatizing clinical setting and their interaction quality with sexual minority men (SMM) patients in Zambia. In 2021, a cross-sectional survey was conducted with 91 HCPs offering HIV-related services to SMM in Zambia. Path analysis was conducted to examine the potential mediation effect of "perceived HIV stigma" and "HIV infection concern" among HCPs in the association between "stigmatizing clinical setting" and their "interaction quality with SMM". Mediators i.e., "perceived HIV stigma" and "HIV infection concern" among HCPs, were associated positively with the stigmatizing clinical setting (ß = 0.329, p < .01, ß = 0.917, p < 0.01), and negatively with physician-patient interaction quality (ß = -0.167, p = 0.051; ß = -0.126, p < 0.05). Stigmatizing clinical setting had a significant and negative indirect effect on HCPs interaction quality with SMM through increased perceived HIV stigma (z = -1.966, p < 0.05) and increased HIV infection concern (z = -1.958, p = 0.050). To improve physician-patient interaction quality, stigma reduction interventions among HCPs, who serve SMM in Zambia, should target development of development of inclusive policies and the cultivation of cultural norms that are supportive and respectful to SMM, and protection of HCPs from enacted stigma due to offering care to SMM.

Impact of enacted stigma on mental health, substance use, and HIV-related behaviors among sexual minority men in Zambia.

Sexual minority men (SMM) in Zambia face significant challenges including stigma, discrimination, and mental health issues, which further impact their HIV-related risk behaviors. This study aimed to investigate the associations between enacted stigma, substance abuse, HIV-related behaviors, and mental health (i.e., depression, anxiety, and post-traumatic stress disorder [PTSD] symptoms) among SMM in Zambia. SMM aged 18-35 years who reported having multiple and/or concurrent sexual partners or low and/or inconsistent condom use in the past three months were recruited from four districts in Zambia between February and November 2021. Participants completed an anonymous interviewer-administered survey. Key variables of interest were compared between participants with higher vs. lower levels of enacted stigma. Independent samples t-tests were used for continuous variables, and chi-squared tests were used for categorical variables. A total of 197 eligible SMM participated in the study (mean age = 24.41 years). Participants with a higher level of enacted stigma showed a higher level of anxiety symptoms (χ2 = 12.91, p ≤ .001), PTSD symptoms (χ2 = 7.13, p < .01), tobacco use (χ2 = 10.47, p < .01), cannabis use (χ2 = 5.90, p < .05), and a higher number of sexual partners (t = 1.99, p < .05) in the past three months. Stigma reduction interventions may help mitigate substance abuse, HIV-related behaviors, and adverse mental health outcomes among SMM in Zambia. Health care providers, especially psychiatric-mental health nurses, can incorporate strategies for recognizing and addressing stigma into their practice through training and integrate multiple resources to create an inclusive and non-judgmental environment for SMM to improve their well-being.

Physician-Patient Interaction Quality Mediates the Association Between HIV-Related Stigma and HIV-Prevention Behaviors Among Sexual Minority Men in Zambia.

HIV-related stigma is a major challenge to HIV prevention for sexual minority men (SMM) in Zambia, but little is known about the underlying mechanisms. This study aimed to investigate whether physician-patient interaction quality mediates the relationship between HIV-related stigma and HIV-prevention behaviors among SMM. Data were collected using a cross-sectional survey from 194 SMM (aged: mean = 24.08, SD = 4.27) across four districts in Zambia between February and November 2021. Participants were asked about their demographic characteristics, HIV-related stigma, SMM-related stigma, physician-patient interaction quality, HIV-testing intention, and use of pre-exposure prophylaxis (PrEP). Path analysis was used to test the mediation effect of physician-patient interaction quality in the associations of HIV-related stigma/SMM-related stigma with HIV-testing intention and current PrEP use. Higher self-reported physician-patient interaction quality was negatively associated with HIV-related stigma (ß = - 0.444, z = - 2.223, p < 0.05), and positively associated with HIV-testing intention (ß = 0.039, z = 5.121, p < 0.001) and current PrEP use (ß = 0.008, z = 2.723, p < 0.01). HIV-related stigma among SMM had a significant and negative indirect effect on HIV-testing intention (ß = - 0.017, z = - 2.006, p < 0.05), and current PrEP use (ß = - 0.004, z = - 2.009, p < 0.05) through physician-patient interaction quality. Contrary to our expectations, SMM-related stigma did not have a significant and negative indirect effect on HIV prevention behaviors through physician-patient interaction quality. Health interventions need to improve physician-patient interaction quality by offering healthcare provider training, targeting HIV-related stigma in healthcare settings, and devising inclusive healthcare policies to promote HIV prevention efforts.

Successful Goal Attainment: Longitudinal Effects of Goal Commitment and Implicit Motives Among German and Zambian Adolescents.

Goal commitment typically relates to successful goal realization. Yet, individuals differ in how much their goals correspond to their implicit motives. We hypothesized that for those adolescents high in a given implicit motive, goal commitment and goal success in the corresponding motive domain (i.e., achievement, affiliation, power) are more closely related than for those low in the implicit motive. Data were assessed in an individualistic (Germany) and a collectivistic cultural context (Zambia) on two measurement occasions (i.e., T1: Picture Story Exercise for implicit motives; T1 and T2: GOALS questionnaire for goal commitment and success, respectively). Goal success at T2 was reliably predicted by goal importance and goal success at T1, respectively. The hypothesized interaction was found only for the implicit power motive but not for the implicit needs of achievement and affiliation, respectively. Results were equivalent across adolescents' cultural backgrounds. Findings are discussed with respect to motive-specific effects on goal dimensions.

External Validation and Comparison of Clostridioides difficile Severity Scoring Systems.

BACKGROUND: Many models have been developed to predict severe outcomes from Clostridioides difficile infection (CDI). These models are usually developed at a single institution and largely are not externally validated. Our aim in this study was to validate previously published risk scores in a multicenter cohort of patients with CDI. METHODS: This was a retrospective study on 4 inpatient cohorts with CDI from 3 distinct sites: the universities of Michigan (2010-2012 and 2016), Chicago (2012), and Wisconsin (2012). The primary composite outcome was admission to an intensive care unit, colectomy, and/or death attributed to CDI within 30 days of positive testing. Both within each cohort and combined across all cohorts, published CDI severity scores were assessed and compared to each other and the Infectious Diseases Society of America (IDSA) guideline definitions of severe and fulminant CDI. RESULTS: A total of 3646 patients were included for analysis. Including the 2 IDSA guideline definitions, 14 scores were assessed. Performance of scores varied within each cohort and in the combined set (mean area under the receiver operator characteristic curve [AuROC], 0.61; range, 0.53-0.66). Only half of the scores had performance at or better than IDSA severe and fulminant definitions (AuROCs of 0.64 and 0.63, respectively). Most of the scoring systems had more false than true positives in the combined set (mean, 81.5%; range, 0%-91.5%). CONCLUSIONS: No published CDI severity score showed stable, good predictive ability for adverse outcomes across multiple cohorts/institutions or in a combined multicenter cohort.

Written Advice Given by African American Smokers to Their Peers: Qualitative Study of Motivational Messages.

BACKGROUND: Although African Americans have the lowest rates of smoking onset and progression to daily smoking, they are less likely to achieve long-term cessation. Interventions tailored to promote use of cessation resources in African American individuals who smoke are needed. In our past work, we demonstrated the effectiveness of a technology-assisted peer-written message intervention for increasing smoking cessation in non-Hispanic White smokers. In this formative study, we have adapted this intervention to be specific for African American smokers. OBJECTIVE: We aimed to report on the qualitative analysis of messages written by African American current and former smokers for their peers in response to hypothetical scenarios of smokers facing cessation challenges. METHODS: We recruited African American adult current and former smokers (n=41) via ResearchMatch between April 2017 and November 2017. We asked participants to write motivational messages for their peers in response to smoking-related hypothetical scenarios. We also collected data on sociodemographic factors and smoking characteristics. Thematic analysis was conducted to identify cessation strategies suggested by the study participants. RESULTS: Among the study participants, 60% (25/41) were female. Additionally, more than half (23/41, 56%) were thinking about quitting, 29% (12/41) had set a quit date, and 27% (11/41) had used electronic cigarettes in the past 30 days. Themes derived from the qualitative analysis of peer-written messages were (1) behavioral strategies, (2) seeking help, (3) improvements in quality of life, (4) attitudes and expectations, and (5) mindfulness/religious or spiritual practices. Under the behavioral strategies theme, distraction strategies were the most frequently suggested strategies (referenced 84 times in the 318 messages), followed by use of evidence-based treatments/cessation strategies. Within the seeking help theme, subthemes included seeking help or support from family/friends or close social networks (referenced 56 times) and health care professionals (referenced 22 times). The most frequent subthemes that emerged from improvements in the quality of life theme included improving one's health (referenced 22 times) and quality of life (referenced 21 times). Subthemes that emerged from the attitude and expectations theme included practicing positive self-talk (referenced 27 times), autonomy/independence from the smoking habit (referenced six times), and financial cost of smoking (referenced five times). The two subthemes that emerged from the mindfulness/religious or spiritual practices theme were use of self-awareness techniques (referenced 36 times) and religious or spiritual practices to cope (referenced 13 times). CONCLUSIONS: Our approach to adapt a prior peer-message intervention to African American smokers yielded a set of evidence-based messages that may be suitable for smokers at all phases of motivation to quit (ready to quit or not ready to quit). In future research, we plan to assess the impact of texting these messages to African American smokers in a smoking cessation trial.

The Impact of the Affordable Care Act Medicaid Expansion on Racial/Ethnic and Sex Disparities in HIV Testing: National Findings from the Behavioral Risk Factor Surveillance System.

INTRODUCTION: Over half of Americans have not been tested for HIV in their lifetime, and over a third of all HIV diagnoses are made less than a year before progression to AIDS. The Affordable Care Act (ACA) Medicaid expansion of 2014 had potential to improve HIV and other health screenings. We assessed the differential impacts of Medicaid expansion on racial/ethnic and racial/ethnic-sex disparities in HIV testing. METHODS: Using Behavioral Risk Factor Surveillance System data from all 50 states and D.C., we sampled low-income (≤ 138% of the federal poverty level) adults ages 19-64 who were non-pregnant and non-disabled. Using a difference-in-differences (DD) and triple difference-in-differences (DDD) study design, we assessed differential impacts by race/ethnicity (White, Black, Hispanic, and other) and race/ethnicity-sex between 2011 and 2013 and 2014-2018. Outcomes were (1) ever having received an HIV test and (2) having received an HIV test in the last year. RESULTS: Overall, Medicaid expansion was associated with a significant increase in HIV testing (p = 0.003). White females and Black males appeared most likely to benefit from this increase (DD 4.5 and 4.8 percentage points; p = 0.001 and 0.130 respectively). However, despite having baseline higher rates of HIV diagnosis, Black and Hispanic females did not have increased rates of ever having HIV testing following Medicaid expansion (DD - 1.9 and 0.9 percentage points; p = 0.391 and 0.703, respectively), including when compared to a White male reference subgroup and across other race/ethnicity-sex subgroups. CONCLUSIONS: Medicaid expansion was associated with an increased overall probability of HIV testing among low-income, nonelderly adults, but certain groups including Black females were not more likely to benefit from this increase, despite being disproportionately affected by HIV at baseline. Targeted and culturally informed interventions to increase Medicaid enrollment and access to primary care may be needed to expand HIV testing in vulnerable groups.

Changes in the Association Between Diagnostic Testing Method, Polymerase Chain Reaction Ribotype, and Clinical Outcomes From Clostridioides difficile Infection: One Institution's Experience.

BACKGROUND: In Clostridioides difficile infection (CDI), the relationship between clinical, microbial, and temporal/epidemiological trends, disease severity and adverse outcomes is incompletely understood. In a follow-up to our study from 2010-2013, we evaluate stool toxin levels and C. difficile polymerase chain reaction (PCR) ribotypes. We hypothesized that elevated stool toxins and infection with ribotype 027 associate with adverse outcomes. METHODS: In 565 subjects at the University of Michigan with CDI diagnosed by positive testing for toxins A/B by enzyme immunoassay (EIA) or PCR for the tcdB gene, we quantified stool toxin levels via a modified cell cytotoxicity assay (CCA), isolated C. difficile by anaerobic culture, and performed PCR ribotyping. Severe CDI was defined by Infectious Diseases Society of America (IDSA) criteria, and primary outcomes were all-cause 30-day mortality and a composite of colectomy, intensive care unit admission, and/or death attributable to CDI within 30 days. Analyses included bivariable tests and logistic regression. RESULTS: 199 samples were diagnosed by EIA; 447 were diagnosed by PCR. Toxin positivity associated with IDSA severity but not primary outcomes. In 2016, compared with 2010-2013, ribotype 106 newly emerged, accounting for 10.6% of strains, ribotype 027 fell from 16.5% to 9.3%, and ribotype 014-027 remained stable at 18.9%. Ribotype 014-020 associated with IDSA severity and 30-day mortality (P = .001). CONCLUSIONS: Toxin positivity by EIA and CCA associated with IDSA severity but not with subsequent adverse outcomes. The molecular epidemiology of C. difficile has shifted, which may have implications for the optimal diagnostic strategy for and clinical severity of CDI.

Early Serratus Plane Block for Rib Fracture Management could Avoid Intensive Care Unit Admission.

How to cite this article: Gorecha M, Menon A, Woodford E, Yahia S, Marimuthu K. Early Serratus Plane Block for Rib Fracture Management could Avoid Intensive Care Unit Admission. Indian J Crit Care Med 2020;24(10):995.

Benign Multicystic Peritoneal Mesothelioma Presenting as Appendiceal Abscess: A Diagnostic and Therapeutic Challenge.

Primary peritoneal tumors are rarely encountered and their management is usually challenging for the clinicians. Especially when the patients with advanced peritoneal malignancy present as surgical emergencies, usually with symptoms of obstruction, perforation or gross space-occupying lesions, the on-call surgical team has to weigh the pros and cons of urgent versus delayed treatment and plans a safe and simultaneously oncologically beneficial therapeutic approach. Herein, we present a case of a Caucasian man who was referred as suspected complicated appendicitis by his primary care physician, with the final diagnosis being benign multicystic mesothelioma. We describe the challenges of the clinical decision making for the emergency general surgeon and relevant diagnostic and therapeutic pitfalls, which can be potentially minimized by early liaison with tertiary units specializing in the treatment of disseminated peritoneal malignancy.

Systemic Inflammatory Mediators Are Effective Biomarkers for Predicting Adverse Outcomes in Clostridioides difficile Infection.

Clostridioides difficile infection (CDI) can result in severe disease and death, with no accurate models that allow for early prediction of adverse outcomes. To address this need, we sought to develop serum-based biomarker models to predict CDI outcomes. We prospectively collected sera ≤48 h after diagnosis of CDI in two cohorts. Biomarkers were measured with a custom multiplex bead array assay. Patients were classified using IDSA severity criteria and the development of disease-related complications (DRCs), which were defined as ICU admission, colectomy, and/or death attributed to CDI. Unadjusted and adjusted models were built using logistic and elastic net modeling. The best model for severity included procalcitonin (PCT) and hepatocyte growth factor (HGF) with an area (AUC) under the receiver operating characteristic (ROC) curve of 0.74 (95% confidence interval, 0.67 to 0.81). The best model for 30-day mortality included interleukin-8 (IL-8), PCT, CXCL-5, IP-10, and IL-2Rα with an AUC of 0.89 (0.84 to 0.95). The best model for DRCs included IL-8, procalcitonin, HGF, and IL-2Rα with an AUC of 0.84 (0.73 to 0.94). To validate our models, we employed experimental infection of mice with C. difficile Antibiotic-treated mice were challenged with C. difficile and a similar panel of serum biomarkers was measured. Applying each model to the mouse cohort of severe and nonsevere CDI revealed AUCs of 0.59 (0.44 to 0.74), 0.96 (0.90 to 1.0), and 0.89 (0.81 to 0.97). In both human and murine CDI, models based on serum biomarkers predicted adverse CDI outcomes. Our results support the use of serum-based biomarker panels to inform Clostridioides difficile infection treatment.IMPORTANCE Each year in the United States, Clostridioides difficile causes nearly 500,000 gastrointestinal infections that range from mild diarrhea to severe colitis and death. The ability to identify patients at increased risk for severe disease or mortality at the time of diagnosis of C. difficile infection (CDI) would allow clinicians to effectively allocate disease modifying therapies. In this study, we developed models consisting of only a small number of serum biomarkers that are capable of predicting both 30-day all-cause mortality and adverse outcomes of patients at time of CDI diagnosis. We were able to validate these models through experimental mouse infection. This provides evidence that the biomarkers reflect the underlying pathophysiology and that our mouse model of CDI reflects the pathogenesis of human infection. Predictive models can not only assist clinicians in identifying patients at risk for severe CDI but also be utilized for targeted enrollment in clinical trials aimed at reduction of adverse outcomes from severe CDI.

Medical Students Are Not Essential Workers: Examining Institutional Responsibility During the COVID-19 Pandemic.

In light of the evolving COVID-19 pandemic, the Association of American Medical Colleges (AAMC) and Liaison Committee on Medical Education (LCME) released a joint statement in March 2020 recommending an immediate suspension of medical student participation in direct patient contact. As graduating medical students who will soon begin residency, the authors fully support this recommendation. Though paid health care workers, like residents, nurses, and environmental services staff, are essential to the management of COVID-19 patients, medical students are not. Students' continued involvement in direct patient care will contribute to SARS-CoV-2 exposures and transmissions and will waste already limited personal protective equipment. By decreasing nonessential personnel in health care settings, including medical students, medical schools will contribute to national and global efforts to "flatten the curve."The authors also assert that medical schools are responsible for ensuring medical student safety. Without the protections provided to paid health care workers, students are uniquely disadvantaged within the medical hierarchy; these inequalities must be addressed before medical students are safely reintegrated into clinical roles. Although graduating medical students and institutional leadership may worry that suspending clinical rotations might prevent students from completing graduation requirements, the authors argue the ethical obligation to "flatten the curve" supersedes usual teaching responsibilities. Therefore, the authors request further guidance from the LCME and AAMC regarding curricular exemptions/alternatives and adjusted graduation timelines. The pool of graduating medical students affected by this pause in direct patient contact represents a powerful reserve, which may soon need to be used as the COVID-19 pandemic continues to challenge the U.S. health care infrastructure.

Comparing mortality risk models in VLBW and preterm infants: systematic review and meta-analysis.

OBJECTIVE: To compare the prognostic accuracy of six neonatal illness severity scores (CRIB, CRIB II, SNAP, SNAP II, SNAP-PE, and SNAP-PE II), birthweight (BW), and gestational age (GA) for predicting pre-discharge mortality among very low birth weight (VLBW) infants (<1500 g) and very preterm infants (<32 weeks' gestational age). STUDY DESIGN: PubMed, EMBASE, and Scopus were the data sources searched for studies published before January 2019. Data were extracted, pooled, and analyzed using random-effects models and reported as AUC with 95% confidence intervals (CI). RESULTS: Of 1659 screened studies, 24 met inclusion criteria. CRIB was the most discriminate for predicting pre-discharge mortality [AUC 0.88 (0.86-0.90)]. GA was the least discriminate [AUC 0.76 (0.72-0.80)]. CONCLUSIONS: Although the original CRIB score was the most accurate predictor of pre-discharge mortality, significant heterogeneity between studies lowers confidence in this pooled estimate. A more precise illness severity score to predict pre-discharge mortality is still needed.

Perspectives on ART adherence among Zambian adults living with HIV: insights raised using HIV-related disability frameworks.

Anti-retroviral treatment (ART) has improved the survival of people living with HIV in Africa. Living with chronic HIV comes with new health and functional challenges and the need to manage ART adherence. The Sepo Study applied disability frameworks to better understand living with chronic HIV while using ART. The study followed 35 people (18 women, 17 men) living with HIV and on ART 6 months or longer in private and public health facilities in Lusaka, Zambia over 18-months (2012-2015). A total of 99 in-depth interviews were conducted. Conventional content analysis and NVIVOv10 were applied to analyse the data. Participants were adhering to ART at the times of the interviews and therefore less likely to report major challenges with adherence. Three main themes emerged from the data related to adherence. Firstly, ART was regarded as "giving life", which underscored adherence. Secondly, all participants described strategies for to managehealth and functional limitations, which they attributed as side-effects or chronicity. Thirdly, participants described experiences of uncertainty, including the efficacy of new regimens, potential loss of functioning, risk of new health problems, and death. Long-term ART managment in Africa needs to integrate rehabilitation approaches to address functional limitations, uncertainties, strengthen and support for adherence.

Development, implementation and dissemination: Couples and Parent-Child Communication Workshops in Zambia.

Over a million people are living with HIV in Zambia, representing ∼13% of the country's population. To increase HIV prevention communication, a community-based communication training program, the Parent-Child and Couples Communication Workshop, was developed from pilot data and culturally tailored for dissemination in Zambia. Workshop trainees (N = 195) were 18 years of age or more and community educators and counselors in the Copperbelt and Southern Provinces of Zambia, e.g., peer educators, lay counselors, teachers, nurses, mentors and program officers, workshops (N = 16) were conducted. Satisfaction with the workshops, readiness to conduct a workshop and implementation were assessed. Overall, readiness to conduct workshops following training and satisfaction with the workshop was similarly high across Provinces. Following the initial training, more than half of workshop trainees conducted workshops in their own communities. Zambian community members were receptive to learning techniques to disseminate communication strategies that could prevent HIV transmission. The use of culturally appropriate strategies and a training of trainers approach for communication and prevention may have enhanced workshop dissemination in Zambian communities. Future research should explore the use of culturally congruent HIV prevention initiatives in the Zambian context.

A randomized-control trial for the teachers' diploma programme on psychosocial care, support and protection in Zambian government primary schools.

Orphaned and vulnerable children (OVC) experience poverty, stigma, and abuse resulting in poor physical, emotional, and psychological outcomes. The Teachers' Diploma Programme on Psychosocial Care, Support, and Protection is a child-centered 15-month long-distance learning program focused on providing teachers with the knowledge and skills to enhance their school environments, foster psychosocial support, and facilitate school-community relationships. A randomized controlled trial was implemented in 2013-2014. Both teachers (n=325) and students (n=1378) were assessed at baseline and 15-months post-intervention from randomly assigned primary schools in Lusaka and Eastern Provinces, Zambia. Multilevel linear mixed models (MLM) indicate positive significant changes for intervention teachers on outcomes related to self-care, teaching resources, safety, social support, and gender equity. Positive outcomes for intervention students related to future orientation, respect, support, safety, sexual abuse, and bullying. Outcomes support the hypothesis that teachers and students benefit from a program designed to enhance teachers' psychosocial skills and knowledge.

Experiences of work among people with disabilities who are HIV-positive in Zambia.

This paper focuses on accounts of how having a disability and being HIV-positive influences experiences of work among 21 people (12 women, 9 men) in Lusaka, Zambia. In-depth semi-structured interviews were conducted in English, Bemba, Nyanja, or Zambian sign language. Descriptive and thematic analyses were conducted. Three major themes were generated. The first, a triple burden, describes the burden of having a disability, being HIV-positive, and being unemployed. The second theme, disability and HIV is not inability, describes participants' desire for work and their resistance to being regarded as objects of charity. Finally, how work influences HIV management, describes the practicalities of working and living with HIV. Together these themes highlight the limited options available to persons with disabilities with HIV in Lusaka, not only secondary to the effects of HIV influencing their physical capacity to work, but also because of the attendant social stigma of being a person with a disability and HIV-positive.

Perceptions of HIV-related health services in Zambia for people with disabilities who are HIV-positive.

INTRODUCTION: Despite the emerging body of literature on increased vulnerability to HIV among people with disabilities (PWDs), there is a dearth of evidence related to experiences of PWDs who have become HIV-positive. This priority was identified by a disability advocacy organization in Lusaka, Zambia, where the prevalence of HIV and of disability is each approximately 15%. The purpose of this study was to explore perceptions and experiences of HIV-related health services for PWDs who are also living with HIV in Lusaka, Zambia. METHODS: This qualitative, interpretive study involved in-depth, semi-structured, one-on-one interviews with two groups of participants in Lusaka, Zambia: 21 PWDs who had become HIV-positive, and 11 people working in HIV and/or disability. PWDs had physical, hearing, visual and/or intellectual impairments. Interviews were conducted in English, Nyanja, Bemba or Zambian sign language. Descriptive and thematic analyses were conducted by a multidisciplinary, international research team. RESULTS: Participants described their experiences with HIV-related health services in terms of the challenges they faced. In particular, they encountered three main challenges while seeking care and treatment: (1) disability-related discrimination heightened when seeking HIV services, (2) communication barriers and related concerns with confidentiality, and (3) movement and mobility challenges related to seeking care and collecting antiretroviral therapy. These experiences were further shaped by participants' profound concerns about poverty and unmet basic needs. DISCUSSION: This study demonstrates how PWDs who are HIV-positive have the same HIV care, treatment and support needs as able-bodied counterparts, but face avoidable barriers to care. Many challenges mirror concerns identified with HIV prevention, suggesting that efforts to promote inclusion and reduce stigma could have widespread benefits. CONCLUSIONS: Despite the growing body of literature on increased risk of exposure to HIV among HIV-negative PWDs, this is the first published study to examine perceptions of testing, treatment and other HIV services for PWDs who have become HIV-positive. Findings reveal far-reaching opportunities for improving the quality of care for this population.

Mental health and disclosure of HIV status in Zambian adolescents with HIV infection: implications for peer-support programs.

OBJECTIVES: To examine emotional and behavioural difficulties in HIV positive Zambian adolescents and to determine the relationship between disclosure of HIV status and mental health. DESIGN: A cross-sectional survey. METHODS: Participants were 127 HIV positive adolescents aged 11 to 15 years recruited through clinics in the Lusaka region. Mental health was assessed using the youth report version of the Strengths and Difficulties Questionnaire (SDQ). Caregivers completed the parent SDQ. Sixty-two participants were invited for a semi-structured interview which probed views on attending a peer support group. RESULTS: Compared to a British community sample participants had increased mental health problems (OR, 2.1), particularly emotional symptoms (OR = 3.6) and peer problems (OR = 7.1). The majority of children (n = 94) were receiving antiretroviral (ARV) treatment, but only 48 children (37.8%) had their HIV status disclosed. Those who had not had their HIV status disclosed were younger (P < 0.001) and less likely to be receiving ARV treatment (P < 0.001). Controlling for these factors they were also more likely to score in the abnormal range of the emotional difficulties subscale (OR = 2.63, 95% CI: 1.11 to 6.26). Of 38 interviews transcribed, content analysis showed that only 3 children were opposed to participation in a peer-group program, with the majority (23/38) expressing reasoned and positive responses, regardless of disclosure status. CONCLUSION: High rates of emotional and peer problems were found in this sample but disclosure of HIV status did not have a negative effect on mental health. Interventions to promote disclosure could facilitate access to emotional and peer support.