Factors associated with stigma related to HIV pre-exposure prophylaxis (PrEP) use among men who have sex with men (MSM).

BACKGROUND: Pre-exposure prophylaxis (PrEP) is a noteworthy scientific development that increases the opportunities for men who have sex with men (MSM) to prevent HIV infection, but stigma is a major barrier to its uptake. This study aims to determine the associations between PrEP-related stigma and individual characteristics among MSM. METHODS: Self-reported cross-sectional data were collected from routine-collected electronic healthcare record data from 4084 MSM receiving PrEP in San Francisco, California, between July 2018 and June 2020. Multivariable logistic regression was performed to determine the associations between individual characteristics and PrEP-related stigma, adjusting for age, race, gender identity, injection history, housing status and mental health status. RESULTS: PrEP-related stigma was experienced by 9.0% of the participants in our study. PrEP-related stigma was significantly associated with being transgender or gender non-conforming (adjusted OR (AOR): 1.81, 95% CI 1.21 to 2.72), having a history of injection drug use (AOR: 2.02, 95% CI 1.18 to 3.46), being unstably housed (AOR: 1.58, 95% CI 1.11 to 2.26) and having mental health concerns (AOR: 1.99, 95% CI 1.35 to 2.92), after controlling for age, race, gender, injection history, housing status and mental health status. CONCLUSION: Participants who reported being transgender or gender non-conforming, having a history of injection drug use, or having mental health concerns were more likely to report experiencing PrEP-related stigma. It is crucial to develop culturally appropriate interventions to reduce PrEP-related stigma among populations who are at high risk of HIV infection and may benefit strongly from improved PrEP uptake.

Impact of Racial Categorization on Effect Estimates: An HIV Stigma Analysis.

Suboptimal racial categorization potentially introduces bias in epidemiologic analysis and interpretation, making it difficult to appropriately measure factors leading to racial health disparities. As part of an analysis focused on predictors of experiencing human immunodeficiency status (HIV)-related stigma among men who have sex with men living with HIV in San Francisco, we struggled with the most appropriate ways to categorize people who reported more than 1 racial identity, and we aimed to explore the implications of different methodological choices in this analysis. We fitted 3 different multivariable linear regression models, each utilizing a different approach to racial categorization: the "multiracial," "othering," and "hypodescent" models. We estimated an adjusted risk difference in mean score for reported frequency of experiencing HIV-related stigma on a 4-point scale, adjusting for age, race, gender identity, injection history, housing, mental health concerns, and viral load. Use of a hypodescent model for racial categorization led to a shift in the point estimate through the null for Blacks/African Americans, and it improved precision for that group. However, it obscured the association of increased stigma and race for multiracial people, compared with monoracial counterparts. We conclude that methodological decisions related to racial categorization of participants can dramatically affect race-related study findings in predictor regression models.

Psychosocial Determinants of HIV Stigma among Men Who Have Sex with Men in San Francisco, California.

BACKGROUND: Stigma and discrimination are major challenges faced by people living with HIV (PLWH), and stigma continues to be prevalent among PLWH. We conducted a cross-sectional study of 584 men who have sex with men (MSM) living with HIV between July 2018 and December 2020, designed to better understand which demographic and behavioral characteristics of MSM living with HIV in San Francisco, California are associated with experience of stigma, so that programs and initiatives can be tailored appropriately to minimize HIV stigma's impacts. METHODS: This analysis was conducted with data from San Francisco AIDS Foundation (SFAF) encompassing services from multiple different locations in San Francisco. Data about the level of HIV-related stigma experienced were collected through a single question incorporated into programmatic data collection forms at SFAF as part of the client record stored in SFAF's electronic health record. We performed linear regression to determine the associations between self-reported experiences of HIV stigma and other characteristics among MSM living with HIV. RESULTS: HIV stigma was low overall among MSM living with HIV who are actively engaged in HIV care in San Francisco; however, it was significantly higher for the age groups of 13-29 years (adjusted risk difference (ARD): 0.251, 95% CI: 0.012, 0.489) and 30-49 years (ARD: 0.205, 95% CI: 0.042, 0.367) when compared to the age group of 50 years and older, as well as people who were homeless (ARD: 0.844, 95% CI: 0.120, 1.568), unstably housed (ARD: 0.326, 95% CI: 0.109, 0.543) and/or having mental health concerns (ARD: 0.309, 95% CI: 0.075, 0.544), controlling for race, injection history, and viral load. CONCLUSIONS: These findings highlight an opportunity to develop culturally, socially, and racially appropriate interventions to reduce HIV stigma among MSM living with HIV, particularly for younger men and those struggling with housing stability and/or mental health.

Defending Comprehensive Tobacco Control Policy Implementation in Nepal From Tobacco Industry Interference (2011-2018).

INTRODUCTION: Nepal passed a comprehensive tobacco control law in 2011. Tobacco control advocates successfully countered tobacco industry (TI) interference to force implementation of law. AIMS AND METHODS: Policy documents, news stories, and key informant interviews were triangulated and interpreted using the Policy Dystopia Model (PDM). RESULTS: The TI tried to block and weaken the law after Parliament passed it. Tobacco control advocates used litigation to force implementation of the law while the TI used litigation in an effort to block implementation. The TI argued that tobacco was socially and economically important, and used front groups to weaken the law. Tobacco control advocates mobilized the media, launched public awareness campaigns, educated the legislature, utilized lawsuits, and monitored TI activities to successfully counter TI opposition. CONCLUSIONS: Both tobacco control advocates and the industry used the discursive and instrumental strategies described in the PDM. The model was helpful for understanding TI activities in Nepal and could be applied to other low- and middle-income countries. Civil society, with the help of international health groups, should continue to track TI interference and learn the lessons from other countries to proactively to counter it. IMPLICATIONS: The PDM provides an effective framework to understand battles over implementation of a strong tobacco control law in Nepal, a low- and middle-income country. The TI applied discursive and instrumental strategies in Nepal in its efforts to weaken and delay the implementation of the law at every stage of implementation. It is important to continuously monitor TI activities and learn lessons from other countries, as the industry often employ the same strategies globally. Tobacco control advocates utilized domestic litigation, media advocacy, and engaged with legislators, politicians, and other stakeholders to implement a strong tobacco control law. Other low- and middle-income countries can adapt these lessons from Nepal to achieve effective implementation of their laws.

Exceeding WHO Framework Convention on Tobacco Control (FCTC) Obligations: Nepal Overcoming Tobacco Industry Interference to Enact a Comprehensive Tobacco Control Policy.

BACKGROUND: The tobacco industry works to block, delay, and weaken national tobacco control legislation to implement the WHO Framework Convention on Tobacco Control (FCTC). This article reviews how Nepal overcame industry opposition and to a comprehensive tobacco control law implementing the FCTC. METHODS: We triangulated newspaper articles and policy documents with key informant interviews. RESULTS: With the support of international health groups, local tobacco control advocates worked with policymakers in Nepal to pass a comprehensive tobacco control law that exceeded FCTC obligations. The tobacco industry exploited a time of political transition to block consideration by Parliament, arranged and sponsored foreign tours for legislators, made death threats to tobacco control advocates and their families, and argued for the economic importance of tobacco farms. Despite strong interference from Health, and Law and Justice ministers, a 2009 Supreme Court ruling helped tobacco control advocates secure a comprehensive tobacco control law in 2011 that included rotating pictorial health warning labels covering 75% of both sides of cigarette packages, 100% smoke free public places and workplaces, private homes and vehicles, and a tobacco advertising, promotion, and sponsorship ban. CONCLUSIONS: Advocates in developing countries should utilize Nepal's experience to reject tobacco industry offers of compromise and continue educating politicians and legislators to generate political support to pass a comprehensive tobacco control law. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak (the abstract in Nepali is available as a Supplementary Material). IMPLICATIONS: The tobacco industry exploited a time of political transition in Nepal in its effort to block comprehensive tobacco control policy in Parliament by sponsoring foreign tours of legislatures, making death threats to tobacco control advocates and their families, and arguing for the economic importance of tobacco farms. Tobacco control advocates used litigation to raise awareness and educate legislators and promote strong legislation with the involvement of international health groups. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak.

Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis.

INTRODUCTION: E-cigarettes deliver an aerosol of nicotine by heating a liquid and are promoted as an alternative to combustible tobacco. This study determines the longitudinal associations between e-cigarette use and respiratory disease controlling for combustible tobacco use. METHODS: This was a longitudinal analysis of the adult Population Assessment of Tobacco and Health Waves 1, 2, and 3. Multivariable logistic regression was performed to determine the associations between e-cigarette use and respiratory disease, controlling for combustible tobacco smoking, demographic, and clinical variables. Data were collected in 2013-2016 and analyzed in 2018-2019. RESULTS: Among people who did not report respiratory disease (chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma) at Wave 1, the longitudinal analysis revealed statistically significant associations between former e-cigarette use (AOR=1.31, 95% CI=1.07, 1.60) and current e-cigarette use (AOR=1.29, 95% CI=1.03, 1.61) at Wave 1 and having incident respiratory disease at Waves 2 or 3, controlling for combustible tobacco smoking, demographic, and clinical variables. Current combustible tobacco smoking (AOR=2.56, 95% CI=1.92, 3.41) was also significantly associated with having respiratory disease at Waves 2 or 3. Odds of developing respiratory disease for a current dual user (e-cigarette and all combustible tobacco) were 3.30 compared with a never smoker who never used e-cigarettes. Analysis controlling for cigarette smoking alone yielded similar results. CONCLUSIONS: Use of e-cigarettes is an independent risk factor for respiratory disease in addition to combustible tobacco smoking. Dual use, the most common use pattern, is riskier than using either product alone.

Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health.

Background E-cigarettes are popular for smoking cessation and as an alternative to combustible cigarettes. We assess the association between e-cigarette use and having had a myocardial infarction ( MI ) and whether reverse causality can explain the observed cross-sectional association between e-cigarette use and MI . Methods and Results Cross-sectional analysis of the Population Assessment of Tobacco and Health Wave 1 for association between e-cigarette use and having had and MI . Longitudinal analysis of Population Assessment of Tobacco and Health Waves 1 and 2 for reverse causality analysis. Logistic regression was performed to determine the associations between e-cigarette initiation and MI , adjusting for cigarette smoking, demographic and clinical variables. Every-day (adjusted odds ratio, 2.25, 95% CI : 1.23-4.11) and some-day (1.99, 95% CI : 1.11-3.58) e-cigarette use were independently associated with increased odds of having had an MI with a significant dose-response ( P<0.0005). Odds ratio for daily dual use of both products was 6.64 compared with a never cigarette smoker who never used e-cigarettes. Having had a myocardial infarction at Wave 1 did not predict e-cigarette use at Wave 2 ( P>0.62), suggesting that reverse causality cannot explain the cross-sectional association between e-cigarette use and MI observed at Wave 1. Conclusions Some-day and every-day e-cigarette use are associated with increased risk of having had a myocardial infarction, adjusted for combustible cigarette smoking. Effect of e-cigarettes are similar as conventional cigarette and dual use of e-cigarettes and conventional cigarettes at the same time is risker than using either product alone.

Life expectancy and disparities in survival among HIV-infected people receiving antiretroviral therapy: an observational cohort study in Kathmandu, Nepal.

INTRODUCTION: The advent of antiretroviral therapy (ART) has dramatically slowed down the progression of HIV. This study assesses the disparities in survival, life expectancy and determinants of survival among HIV-infected people receiving ART. METHODS: Using data from one of Nepal's largest population-based retrospective cohort studies (in Kathmandu, Nepal), we followed a total of 3191 HIV-infected people aged 15 years and older who received ART over the period of 2004-2015. We created abridged life tables with age-specific survival rates and life expectancy, stratified by sex, ethnicity, CD4 cell counts and the WHO-classified clinical stage at initiation of ART. RESULTS: HIV-infected people who initiated ART with a CD4 cell count of >200 cells/cm3 at 15 years had 27.4 (22.3 to 32.6) years of additional life. People at WHO-classified clinical stage I and 15 years of age who initiated ART had 23.1 (16.6 to 29.7) years of additional life. Life expectancy increased alongside the CD4 cell count and decreased as clinical stages progressed upward. The study cohort contributed 8484.8 person years, with an overall survival rate of 3.3 per 100 person years (95% CI 3.0 to 3.7). CONCLUSIONS: There are disparities in survival among HIV-infected people in Nepal. The survival payback of ART is proven; however, late diagnosis or the health system as a whole will affect the control and treatment of the illness. This study offers evidence of the benefits of enrolling early in care in general and ART in particular.

Exposure to household tobacco smoke and risk of cancer morbidity and mortality: Analysis of data from the Afghanistan Demographic and Health Survey 2015.

Active and secondhand tobacco exposures are major causes of cancer. Cancer prevention efforts are particularly relevant in resource-constrained settings in which significant barriers to early detection and cancer treatments contribute to poor outcomes. We assess the associations between exposure to household tobacco smoke and cancer morbidity and mortality. We used household data from Afghanistan Demographic and Health Survey, which was a national cross-sectional survey that applied a two-stage stratified random sampling technique in 2015 and 2016. We performed regression analysis to estimate associations between exposure to household tobacco smoke and cancer morbidity and mortality at the household level. Exposure to household tobacco smoke was significantly associated with household reports of a history of any cancer (Adjusted Odds Ratio (AOR): 1.90; 95% Confidence Interval (CI): 1.44, 2.51), breast cancer (1.59; 1.00, 2.55), lung cancer (2.88; 1.58, 5.27), and liver cancer (2.56; 1.10, 5.96), compared to households with no tobacco smoke exposure. These associations persisted after controlling for household location, wealth index, type of cooking fuel used in house, and location of food preparation. Households in a rural location experienced significantly higher mortality of any cancer (4.40; 95% CI: 1.57, 12.38), breast cancer (2.91; 1.02, 8.25), and liver cancer (3.91; 1.29, 11.89) vs. those in an urban location. Exposure to household tobacco smoke is a risk factor for cancer morbidity in Afghanistan. Strategies to implement comprehensive smoking cessation and smoke free housing policies are urgently needed as primary cancer prevention strategy in Afghanistan and comparable resource-constrained settings.

Parental tobacco use and child death: analysis of data from demographic and health surveys from South and South East Asian countries.

BACKGROUND: Child mortality is a public health challenge in developing countries, and exposure to second-hand smoke and prenatal exposure to smokeless tobacco are risk factors for child death. We determined the associations between parental tobacco use and child death under the age of five in eight South and South East Asian countries. METHODS: We analysed cross-sectional demographic and health survey data collected between 2005 and 2016, using multiple logistic regressions to estimate the unadjusted and adjusted associations between parental tobacco use and child death, accounting for demographic and economic covariates. RESULTS: Overall prevalence of tobacco smoking was 46.8% for fathers and 2.7% for mothers, smokeless tobacco use was 32.6% for fathers and 7.8% for mothers and any tobacco use was 67.1% for fathers and 10.1% for mothers. Adjusted for demographic and economic covariates, child death was significantly associated with fathers' [odds ratio: 1.10; 95% confidence interval (CI): 1.03, 1.17] and mothers' (1.44; 1.23, 1.70) smoking tobacco, fathers' (1.25; 1.17, 1.34) and mothers' (1.11; 1.00, 1.23) use of smokeless tobacco and fathers' (1.21; 1.13, 1.29) and mothers' (1.24; 1.12, 1.36) use of any tobacco. CONCLUSIONS: Both smoked tobacco and smokeless tobacco policies should be aggressively implemented in public places and workplaces in developing countries, because they stimulate voluntary smoke and smokeless tobacco-free policies in homes.

Tobacco smoking and alcohol drinking among HIV infected people using antiretroviral therapy.

INTRODUCTION: Tobacco smoking, common in people living with human immunodeficiency virus (HIV), is associated with increased mortality and morbidity. This study aimed to determine the proportion of current smokers, as well as assess the factors associated with tobacco smoking and drinking alcohol, among people living with HIV (PLHIV) in Nepal. METHODS: A cross-sectional study was conducted at an antiretroviral therapy (ART) clinic in Kathmandu, Nepal between September and December 2014. Data were collected among 132 HIV infected individuals using a random sampling technique and face-to-face interview. Binary logistic regression analysis was performed to estimate the factors associated with current tobacco smoking and drinking of alcohol. RESULTS: Among the HIV infected people, the proportion of current tobacco smoking was 26.5% (95% Confidence Interval (CI): 18.9-34.1), while drinking of alcohol was 22.7% (95% CI: 15.5-30.0). The respondents who were infected with HIV, after sexual contact with sex workers, were more likely to smoke tobacco (OR=15.2, 95% CI: 4.35-53.08) and drink alcohol (OR=4.50, 95% CI: 1.70-11.93) than those who were infected from drug needle use and blood transfusion. HIV infected individuals, who forgot to take ART medication, were three times more likely (OR=3.17, 95% CI: 1.36-7.38) to drink alcohol than those who did not forget to take ART medication. CONCLUSIONS: Proportion of people who smoke tobacco and drink alcohol is high among the HIV infected individuals who had sexual contact with sex workers in Nepal. There is an urgent need to develop immediate, sustainable and efficient programs to control tobacco smoking and alcohol drinking among vulnerable populations in low and middle-income countries like Nepal. ABBREVIATIONS: HIV: Human Immunodeficiency Virus, AIDS: Acquired Immunodeficiency Syndrome, ART: Antiretroviral Therapy, PLHIV: People Living with Human Immunodeficiency Virus, CI: Confidence Interval, STIDH: Sukraraj Tropical and Infectious Disease Hospital, OR: Odds Ratio, SD: Standard Deviation.

A cluster-randomized evaluation of an intervention to increase skilled birth attendant utilization in mid- and far-western Nepal.

Skilled birth attendant (SBA) utilization is low in remote and rural areas of Nepal. We designed and implemented an evaluation to assess the effectiveness of a five-component intervention that addressed previously identified barriers to SBA services in mid- and far-western Nepal. We randomly and equally allocated 36 village development committees with low SBA utilization among 1-year intervention and control groups. The eligible participants for the survey were women that had delivered a baby within the past 12 months preceding the survey. Implementation was administered by trained health volunteers, youth groups, mothers' groups and health facility management committee members. Post-intervention, we used difference-in-differences and mixed-effects regression models to assess and analyse any increase in the utilization of skilled birth care and antenatal care (ANC) services. All analyses were done by intention to treat. Our trial registration number was ISRCTN78892490 (http://www.isrctn.com/ISRCTN78892490). Interviewees included 1746 and 2098 eligible women in the intervention and control groups, respectively. The 1-year intervention was effective in increasing the use of skilled birth care services (OR = 1.57; CI 1.19-2.08); however, the intervention had no effect on the utilization of ANC services. Expanding the intervention with modifications, e.g. mobilizing more active and stable community groups, ensuring adequate human resources and improving quality of services as well as longer or repeated interventions will help achieve greater effect in increasing the utilization of SBA.

Low-birth-weight babies among hospital deliveries in Nepal: a hospital-based study.

BACKGROUND: Birth weight is an important indicator of a population's health and is associated with numerous interrelated factors in the infant, mother, and physical environment. The objective of this study was to assess the proportion of low birth weight and identify the associated factors for low birth weight in a liveborn infant among the women in Morang, Nepal. METHODS: A cross-sectional survey was carried out from December 2010 to March 2011 among 255 mothers who gave birth during the study period at the Koshi Zonal Hospital, Nepal. Data were collected using a structured questionnaire with face-to-face interviews. Data were analyzed through logistic regression and presented with crude and adjusted odds ratios (AORs) with 95% confidence intervals (CIs). RESULTS: The study showed that the prevalence of low-birth-weight babies was 23.1% (95% CI: 17.9-28.1). The mean (standard deviation) age of mothers was 23.23 (4.18) years. The proportion of low birth weight of previous baby was 3.9% (95% CI: 0.1-7.9), and 15.7% (95% CI: 11.5-20.5) of the respondents had preterm delivery. Nearly one-third (36.1%; 95% CI: 26.4-45.6) of the respondents had >2 years' gap after the previous delivery. Nonformal employment (AOR: 2.14; 95% CI: 0.523-8.74), vegetarian diet (AOR: 1.47; 95% CI: 0.23-9.36), and no rest during pregnancy (AOR: 1.38; 95% CI: 0.41-4.39) were factors more likely to determine low birth weight. However, none of the variables showed a significant association between low birth weight and other dependent variables. CONCLUSION: Low birth weight is an important factor for perinatal morbidity and mortality and is a common problem in the developing world. The proportion of low-birth-weight babies was high in hospital delivery, and ethnicities, Hindu religion, education, nonformal employment, food habit, rest during pregnancy, and type of delivery were found to influence the birth weight. Hence, it is important to strengthen health education services at the basic level of a community to solve this problem.