A pilot pragmatic trial of a "what matters most"-based intervention targeting intersectional stigma related to being pregnant and living with HIV in Botswana.

We conducted a pilot trial of an intervention targeting intersectional stigma related to being pregnant and living with HIV while promoting capabilities for achieving 'respected motherhood' ('what matters most') in Botswana. A pragmatic design allocated participants to the intervention (N = 44) group and the treatment-as-usual (N = 15) group. An intent-to-treat, difference-in-difference analysis found the intervention group had significant decreases in HIV stigma (d = - 1.20; 95% CI - 1.99, - 0.39) and depressive symptoms (d = - 1.96; 95% CI - 2.89, - 1.02) from baseline to 4-months postpartum. Some, albeit less pronounced, changes in intersectional stigma were observed, suggesting the importance of structural-level intervention components to reduce intersectional stigma.

Stigma, Structural Vulnerability, and "What Matters Most" Among Women Living With HIV in Botswana, 2017.

Objectives. To explore whether beneficial health care policies, when implemented in the context of gender inequality, yield unintended structural consequences that stigmatize and ostracize women with HIV from "what matters most" in local culture. Methods. We conducted 46 in-depth interviews and 5 focus groups (38 individuals) with men and women living with and without HIV in Gaborone, Botswana, in 2017. Results. Cultural imperatives to bear children bring pregnant women into contact with free antenatal services including routine HIV testing, where their HIV status is discovered before their male partners'. National HIV policies have therefore unintentionally reinforced disadvantage among women with HIV, whereby men delay or avoid testing by using their partner's status as a proxy for their own, thus facilitating blame toward women diagnosed with HIV. Gossip then defines these women as "promiscuous" and as violating the essence of womanhood. We identified cultural and structural ways to resist stigma for these women. Conclusions. Necessary HIV testing during antenatal care has inadvertently perpetuated a structural vulnerability that propagates stigma toward women. Individual- and structural-level interventions can address stigma unintentionally reinforced by health care policies.

'Mothers moving towards empowerment' intervention to reduce stigma and improve treatment adherence in pregnant women living with HIV in Botswana: study protocol for a pragmatic clinical trial.

BACKGROUND: With high rates of HIV and multiple vulnerable subgroups across diverse settings, there is a need for culturally based, HIV stigma reduction interventions. Pregnant women who are living with HIV are especially in need of services to protect not only their own but also their children's lives. Uptake of HIV services worldwide is hindered by stigma towards persons living with HIV/AIDS. While cultural context plays a key role in shaping HIV stigma, these insights have not yet been fully integrated into stigma reduction strategies. By utilizing the "What Matters Most" stigma framework, we propose that an intervention to counter culturally salient aspects of HIV stigma will improve treatment adherence and other relevant outcomes. A pragmatic clinical trial in Botswana will evaluate the "Mothers Moving towards Empowerment" (MME) intervention, which seeks to address HIV stigma in Botswana and to specifically engage pregnant mothers so as to promote antiretroviral therapy (ART) adherence in the postpartum period. METHODS: This study will test MME against treatment as usual (TAU) among pregnant mothers diagnosed with HIV and their infants. Outcomes will be assessed during pregnancy and 16 weeks postpartum. Women who meet eligibility criteria are assigned to MME or TAU. Women assigned to MME are grouped with others with similar estimated delivery dates, completing up to eight intervention group sessions scheduled before week 36 of their pregnancies. Primary outcomes among mothers include (i) reducing self-stigma, which is hypothesized to mediate improvements in (ii) psychological outcomes (quality of life, depression and social functioning), and (iii) adherence to antenatal care and ART. We will also examine a set of follow-up infant birth outcomes (APGAR score, preterm delivery, mortality (at < 16 weeks), birth weight, vaccination record, and HIV status). DISCUSSION: Our trial will evaluate MME, a culturally based HIV stigma reduction intervention using the "What Matters Most" framework, to reduce stigma and improve treatment adherence among pregnant women and their infants. This study will help inform further refinement of MME and preparation for a future large-scale, multisite, randomized controlled trial (RCT) in Botswana. TRIAL REGISTRATION: ClinicalTrials.gov NCT03698981 . Registered on October 8, 2018.

"It's When the Trees Blossom": Explanatory Beliefs, Stigma, and Mental Illness in the Context of HIV in Botswana.

Mental illness is a common comorbidity of HIV and complicates treatment. In Botswana, stigma impedes treatment of mental illness. We examined explanatory beliefs about mental illness, stigma, and interactions between HIV and mental illness among 42 adults, from HIV clinic and community settings, via thematic analysis of interviews. Respondents endorse witchcraft as a predominant causal belief, in addition to drug abuse and effects of HIV. Respondents describe mental illness as occurring "when the trees blossom," underscoring a conceptualization of it as seasonal, chronic, and often incurable and as worse than HIV. Consequently, people experiencing mental illness (PEMI) are stereotyped as dangerous, untrustworthy, and cognitively impaired and discriminated against in the workplace, relationships, and sexually, increasing vulnerability to HIV. Clinical services that address local beliefs and unique vulnerabilities of PEMI to HIV, integration with peer support and traditional healers, and rehabilitation may best address the syndemic by facilitating culturally consistent recovery-oriented care.

Does Diagnosis Make a Difference? Estimating the Impact of an HIV Medication Adherence Intervention for Persons with Serious Mental Illness.

The heightened risk of persons with serious mental illness to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Here we evaluate the interaction between psychiatric diagnosis and response to a community based-intervention targeted at treatment adherence in 236 HIV+ persons with co-occurring mental illness. To examine differential effectiveness of the intervention for categories of patient diagnosis, we reanalyzed the data after stratifying participants into two diagnostic groups: (1) participants with depressive disorders without psychosis and (2) participants with a psychotic or bipolar disorder. Outcomes included viral load and mental health quality of life (SF-12 Mental Health). We found that HIV+ persons with non-psychotic depressive disorders demonstrated a larger decrease in HIV viral load and more improvement in measures of mental health quality of life when compared to HIV+ persons with psychotic and bipolar disorders. We suggest that successful adherence interventions should be informed by psychiatric symptomatology. TRIAL REGISTRATION: clinicaltrials.gov 29 identifier NCT00264823.

Coercion or Caring: The Fundamental Paradox for Adherence Interventions for HIV+ People with Mental Illness.

To determine if an escalating HIV treatment adherence intervention would be considered by participants from a caring or coercive perspective, perceived coercion was examined in 238 community-based dually diagnosed individuals (HIV+ and a serious mental illness) randomized to a treatment-as-usual (TAU) control group or preventing AIDS through health for HIV+ persons (PATH+) Intervention that increased intervention intensity when adherence fell below 80 %. Minor differences were observed in perceived coercion between the PATH+ Intervention and Control groups with perceived coercion marginally higher in the PATH+ group. Latent growth curve analyses indicate that perceived coercion was not related to duration of the intervention for either the PATH+ or Control group. The experience of coercion by HIV+ individuals receiving community-based mental health services was not related to the intensity or duration of delivered services.

Increasing quality of life and reducing HIV burden: the PATH+ intervention.

The heightened risk of persons with serious mental illness (SMI) to contract and transmit human immunodeficiency virus (HIV) is a public health problem. Our objective was test the effectiveness of a community-based advanced practice nurse intervention to promote adherence to HIV and psychiatric treatment regimens call Preventing AIDS Through Health for Positives (PATH+). We enrolled 238 HIV-positive subjects with SMI who were in treatment at community HIV provider agencies from 2004 to 2009. Participants in the intervention group were assigned an advanced practice nurse who provided community-based care management at a minimum of one visit/week and coordinated their medical and mental healthcare for 12 months. A parallel process latent growth curve model using three data points for biomarkers (baseline, 12 and 24 months) and five data points for health related quality of life (baseline, 3, 6, 12, and 24 months) showed moderate to excellent fit for modeling changes in CD4, viral load, and mental and physical SF-12 subscales. Results suggest that positive effects for PATH+ persisted at 24 months; 12 months after the intervention ended. This project demonstrates the effectiveness of a nurse-led, community-based, individually tailored adherence intervention. We demonstrated improved outcomes in individuals with HIV/SMI and regarding health-related quality of life and reductions in disease burden.

Treatment considerations for HIV-infected individuals with severe mental illness.

There has been a general recognition of a syndemic that includes HIV/AIDS and serve mental illnesses including schizophrenia, major depression, bipolar disorder, post-traumatic stress disorder, and others. The pathophysiology and direction of effects between severe mental illness and HIV infection is less clear however, and relatively little work has been done on prevention and treatment for people with these complex, co-occurring conditions. Here we present the most recent work that has been published on HIV and mental illness. Further, we describe the need for better treatments for "triply diagnosed persons"; those with HIV, mental illness, and substance abuse and dependence. Finally, we describe the potential drug-drug interactions between psychotropic medications and anti-retrovirals, and the need for better treatment guidelines in this area. We describe one example of an individually tailored intervention for persons with serious mental illness and HIV (PATH+) that shows that integrated community-based treatments using advanced practice nurses (APNs) as health navigators can be successful in improving health-related quality of life and reducing the burden of disease in these persons.

Tailored treatment for HIV+ persons with mental illness: the intervention cascade.

The public health literature demonstrates disturbingly high HIV risk for persons with a serious mental illness, who are concurrently comorbid for substance abuse. Many HIV positives have not been tested and therefore do not know their status, but for individuals who are triply diagnosed, adherence to HIV treatment results in meaningful reductions in viral loads and CD4 counts. Barriers to treatment compliance are reviewed, low-threshold/low-intensity community-based interventions are discussed, and preliminary evidence is presented for the efficacy of the intervention cascade, defined as an integrated intervention delivered by specially trained nurses who individualize a treatment compliance intervention in real time as an adaptive response to demand characteristics of the individual.

Racial disparities in HIV prevalence and risk behaviors among injection drug users and members of their risk networks.

In the United States, racial differences in the prevalence and incidence of HIV infection and AIDS diagnoses are dramatic. These differences are large, have been recognized for nearly 20 years, and are as yet not well investigated. These disparities show no signs of diminishing and, in fact, are widening, particularly among drug users and women. Most observers of the racial disparities in prevalence and incidence of HIV infections and AIDS diagnoses in the United States have concluded that these disparities exist because prevention messages, supplies, and/or interventions do not effectively reach those at greatest risk of infection. In essence, such interpretations suggest that Blacks and Latinos continue to practice more risk behaviors than Whites. There are much data to suggest that this is, in fact, not true. Evidence from 232 'index' injection drug users and 465 of their drug and sexual network members participating in HIV Prevention Trials Network 037 is presented. These data describe lower use and/or access to drug treatment and needle exchange programs by Black injectors. In addition, data indicate the coexistence of increased prevalence of HIV in the networks of uninfected Black drug users and fewer associated risk behaviors in the networks of Black and Latino indices compared with networks of White indices. Understanding racial disparities in HIV is a critical challenge; yet, risk behaviors alone do not explain observed disparities in infection rates.

Examining racial disparities in HIV: lessons from sexually transmitted infections research.

Racial differences in the prevalence and incidence of HIV infection and AIDS diagnoses in the United States are striking. These differences have been recognized for nearly 20 years, yet they are not well investigated. In this article, we examine 15 factors identified in the sexually transmitted infection (STI) literature to explain the presence of racial/ethnic disparities in STIs. We review findings from these studies and offer suggestions for future research, with the goal of further understanding and reducing disparities in HIV. In general, the STI literature shows that an evaluation of individual behavior is necessary but insufficient on its own to account for racial/ethnic disparities in STIs. Population parameters should be included within models that traditionally include individual-level factors. The 15 factors can be categorized into 3 broad overarching themes: behavioral, prevention participation, and biologic explanations of differentials in STI transmission and infection. Future research that focuses on only 1 of the 15 factors discussed in this review, to the exclusion of others, is likely to yield poor outcomes. Conversely, an emphasis on the interactions of several factors is more likely to produce effective public health interventions and reductions in HIV transmission.