Prevalence of depression, syndemic factors and their impact on viral suppression among female sex workers living with HIV in eThekwini, South Africa.

INTRODUCTION: Over half of female sex workers (FSW) in South Africa are living with HIV and clinical depression has been frequently documented among FSW. Data characterizing structural determinants of depression and the role of syndemic theory, synergistically interacting disease states, on viral suppression among FSW in South Africa are limited. METHODS: Between July 2018-March 2020, non-pregnant, cisgender women (≥ 18 years), reporting sex work as their primary income source, and diagnosed with HIV for ≥ 6 months were enrolled into the Siyaphambili trial in eThekwini, South Africa. Using baseline data, robust Poisson regression models were used to assess correlates of depression and associations between depression and syndemic factors on viral suppression. RESULTS: Of 1,384 participants, 459 (33%) screened positive for depression, defined as a score of ≥ 10 on the PHQ-9. Physical and sexual violence, drug use, alcohol use, anticipated stigma and internalized stigma were univariately associated with depression (all p's < 0.05) and included the multivariate model. In the multivariate regression, prevalence of depression was higher among participants experiencing sexual violence (PR = 1.47 95% CI:1.24,1.73), physical violence 5 times or more in < 6 months (PR = 1.38 95% CI:1.07, 1.80), using illicit drugs in the last month (PR = 1.23 95%:CI 1.04, 1.48), and reporting higher levels of internalized stigma (PR = 1.11, 95% CI:1.04,1.18). Depression in the absence of the Substance Abuse, Violence and AIDS SAVA syndemic factors was associated with increased prevalence of unsuppressed viral load (aPR 1.24; 95% CI:1.08,1.43), and the SAVA substance use and violence syndemic was associated with an increase in unsuppressed viral load among non-depressed FSW (aPR 1.13; 95% CI:1.01, 1.26). Compared to those experiencing neither factors, those jointly experiencing depression and the SAVA syndemics were at increased risk for unsuppressed viral load (aPR 1.15; 95% CI:1.02,1.28). CONCLUSION: Substance use, violence, and stigma were all associated with depression. Depression and syndemic factors (substance use + violence) were related to unsuppressed viral load; we did not observe higher unsuppressed viral load amongst those experiencing both depression and syndemic factors. Our findings point to the need to understand the unmet mental health needs of FSW living with HIV. TRIAL REGISTRATION: Clinical Trial Number: NCT03500172.

Antiretroviral Treatment Sharing among Female sex Workers Living with HIV in eThekwini (Durban), South Africa: Drivers and Implications for Treatment Success.

In South Africa, 62% of female sex workers (FSW) are estimated to be living with HIV. Qualitative research indicates that FSW share antiretroviral therapy (ART) with peers to surmount treatment barriers. We quantitatively described ART sharing, its correlates, and its relationship with viral suppression (VS) among FSW living with HIV in eThekwini, South Africa. Among FSW on ART (n = 890), 30% ever shared (gave and/or received) ART. Sharing ART was more likely among those with higher levels of alcohol use, illicit drug use, depression severity, and physical/sexual violence in the adjusted model. There was a positive, dose-response relationship between number of pills given to peers in the last 30 days and VS likelihood (aPR: 1.05, 95% CI: 1.02, 1.08; p < 0.01). Giving pills may strengthen peer relationships, which may facilitate ART adherence. ART distribution through peer networks holds promise as a context-appropriate intervention for improving ART adherence among FSW in this setting.

Challenges of uptake of kangaroo mother care by parents of preterm and low birth weight infants in Edo State, Nigeria.

The uptake of kangaroo mother care (KMC) which is acclaimed to be an effective and efficient method of neonatal survival has not increased in Edo State even more than a decade since its recommendation by the WHO in Edo State. Nigeria ranks seventh among the ten African countries where newborns have the highest risk of dying with over 700 newborn deaths per10, 000 live births. The study investigated the challenges faced by parents of preterm and low birth weight infants in the uptake of KMC. The design was an exploratory qualitative research design that utilized semi-structured interviews with open-ended questions to interview 13 mothers whose premature babies were admitted in the neonatal intensive unit of a tertiary health facility. Responses were analyzed thematically and reported in codes and themes. Findings: all participants reported similar challenges, which included ridicule from untrusting friends, inadequate information, lack of human and material resources and nurses' poor attitude. Recommendations made were timely information, increase in human and material resources and establishment of KMC dedicated centers by government.

Engaging community health workers in maternal and infant death identification in Khayelitsha, South Africa: a pilot study.

BACKGROUND: Engaging community health workers in a formalised death review process through verbal and social autopsy has been utilised in different settings to estimate the burden and causes of mortality, where civil registration and vital statistics systems are weak. This method has not been widely adopted. We piloted the use of trained community health workers (CHW) to investigate the extent of unreported maternal and infant deaths in Khayelitsha and explored requirements of such a programme and the role of CHWs in bridging gaps. METHODS: This was a mixed methods study, incorporating both qualitative and quantitative methods. Case identification and data collection were done by ten trained CHWs. Quantitative data were collected using a structured questionnaire. Qualitative data were collected using semi-structured interview guides for key informant interviews, focus group discussions and informal conversations. Qualitative data were analysed thematically using a content analysis approach. RESULTS: Although more than half of the infant deaths occurred in hospitals (n = 11/17), about a quarter that occurred at home (n = 4/17) were unreported. Main causes of deaths as perceived by family members of the deceased were related to uncertainty about the quality of care in the facilities, socio-cultural and economic contexts where people lived and individual factors. Most unreported deaths were further attributed to weak facility-community links and socio-cultural practices. Fragmented death reporting systems were perceived to influence the quality of the data and this impacted on the number of unreported deaths. Only two maternal deaths were identified in this pilot study. CONCLUSIONS: CHWs can conduct verbal and social autopsy for maternal and infant deaths to complement formal vital registration systems. Capacity development, stakeholder's engagement, supervision, and support are essential for a community-linked death review system. Policymakers and implementers should establish a functional relationship between community-linked reporting systems and the existing system as a starting point. There is a need for more studies to confirm or build on our pilot findings.

The development and validation of the HIV/AIDS Stigma Instrument - Nurse (HASI-N).

Illness-related stigma remains a serious problem in the management of HIV disease in Africa. This article describes a series of study phases conducted to develop and validate an instrument to measure HIV/AIDS-related stigma as perpetrated and experienced by nurses. Data were collected in Lesotho, Malawi, South Africa, Swaziland and Tanzania, from 2004-2006. The first phase was a qualitative study with focus group participants (n=251) to gather emic and etic descriptions of HIV/AIDS-related stigma in the five countries. Based on the qualitative data, a 46-item instrument was developed and tested during a second phase in the same five countries (n=244). The result of this phase was a 33-item, three-factor instrument with an average Cronbach alpha of 0.85. A third phase tested the instrument in 1474 nurses. The result was a final 19-item instrument, the HIV/AIDS Stigma Instrument - Nurse (HASI-N), comprised of two factors (Nurses Stigmatizing Patients and Nurses Being Stigmatized) with a Cronbach alpha of 0.90. Concurrent validity was tested by comparing the level of stigma with job satisfaction and quality of life. A significant negative correlation was found between stigma and job satisfaction. The HASI-N is the first inductively derived instrument measuring stigma experienced and enacted by nurses. It has the potential to be used not only to measure stigma, but also to develop stigma-reduction interventions.

Coping with HIV-related stigma in five African countries.

People living with HIV (PLWH) and their families are subjected to prejudice, discrimination, and hostility related to the stigmatization of AIDS. This report examines how PLWH cope with HIV-related stigma in the five southern African countries of Lesotho, Malawi, South Africa, Swaziland, and Tanzania. A descriptive qualitative research design was used to explore the experience of HIV-related stigma of PLWH and nurses in 2004. A total of 43 focus groups were conducted with 251 participants (114 nurses, 111 PLWH, and 26 volunteers). In describing incidents of stigma, respondents reported strategies used or observed to cope with those incidents. Nurse reports of coping strategies that they used as well as observed in HIV-infected patients were coded. Coping strategies used by PLWH in dealing with HIV-related stigma were coded. A total of 17 different self-care strategies were identified: restructuring, seeing oneself as OK, letting go, turning to God, hoping, changing behavior, keeping oneself active, using humor, joining a support or social group, disclosing one's HIV status, speaking to others with same problem, getting counseling, helping others to cope with the illness, educating others, learning from others, acquiring knowledge and understanding about the disease, and getting help from others. Coping appears to be self-taught and only modestly helpful in managing perceived stigma.

Disclosure of HIV status: experiences and perceptions of persons living with HIV/AIDS and nurses involved in their care in Africa.

Most people with HIV have disclosed their status to someone, often with mixed results. Most health literature seems to favor disclosure by persons living with acquired immunodeficiency syndrome (AIDS), but it could be that to disclose is not always a good thing. We used a descriptive, qualitative research design to explore the experience of human immunodeficiency virus (HIV) and AIDS stigma of people living with HIV or AIDS and nurses involved in their care in Africa. Focus group discussions were held with respondents. We asked them to relate incidents that they themselves observed, and those that they themselves experienced in the community and in families. Thirty-nine focus groups were conducted in five countries in both urban and rural settings. This article is limited to a discussion of data related to the theme of disclosure only. The sub-themes of disclosure were experiences before the disclosure, the process of disclosure, and responses during and after disclosure.

EXPERIENCES OF HIV/AIDS STIGMA OF PERSONS LIVING WITH HIV/AIDS AND NURSES INVOLVED IN THEIR CARE FROM FIVE AFRICAN COUNTRIES.

The concept of stigma has received significant attention in recent years in the HIV/AIDS literature. Although there is some change towards the positive, AIDS still remains a significantly stigmatized condition. AIDS stigma and discrimination continue to influence people living with and affected by HIV (PLWA), as well as their health-care providers. Unless stigma is conquered, the illness will not be defeated. Due to the burden that HIV/AIDS places on people living in Africa, a five-year project entitled Perceived AIDS Stigma: A Multinational African Study was undertaken. The focus of the first phase of this project was on exploring and describing the meaning and effect of stigma on PLWA from the experiences of PLWA and the nurses involved in their care in five African countries: Lesotho, Swaziland, Malawi, South Africa and Tanzania. An exploratory descriptive qualitative research design was used to explore and describe the experience of stigma through the critical incident method. Purposive voluntary sampling was utilized. Forty-three focus group discussions were held with respondents to relate incidences which they themselves observed, as well as those that they themselves experienced in the community and in families. The transcribed data was analyzed through the technique of open coding using the NVivo 2.0 analysis package. Three types of stigma (received stigma, internal stigma and associated stigma) and several dimensions for each of these types of stigma emerged from the data. Recommendations were made to pursue these findings further.

Validation of the HIV/AIDS Stigma Instrument - PLWA (HASI-P).

This article describes the development and testing of a quantitative measure of HIV/AIDS stigma as experienced by people living with HIV/AIDS. This instrument is designed to measure perceived stigma, create a baseline from which to measure changes in stigma over time, and track potential progress towards reducing stigma. It was developed in three phases from 2003-2006: generating items based on results of focus group discussions; pilot testing and reducing the original list of items; and validating the instrument. Data for all phases were collected from five African countries: Lesotho, Malawi, South Africa, Swaziland and Tanzania. The instrument was validated with a sample of 1,477 persons living with HIV/AIDS from all of the five countries. The sample had a mean age of 36.1 years and 74.1% was female. The participants reported they knew they were HIV positive for an average of 3.4 years and 46% of the sample was taking antiretroviral medications. A six factor solution with 33 items explained 60.72% of the variance. Scale alpha reliabilities were examined and items that did not contribute to scale reliability were dropped. The factors included: Verbal Abuse (8 items, alpha=0.886); Negative Self-Perception (5 items, alpha=0.906); Health Care Neglect (7 items, alpha=0.832); Social Isolation (5 items, alpha=0.890); Fear of Contagion (6 items, alpha=0.795); and Workplace Stigma (2 items, alpha=0.758). This article reports on the development and validation of a new measure of stigma, HIV/AIDS Stigma Instrument - PLWA (HASI-P) providing evidence that supports adequate content and construct validity, modest concurrent validity, and acceptable internal consistency reliability for each of the six subscales and total score. The scale is available is several African languages.

Verbal and physical abuse and neglect as manifestations of HIV/AIDS stigma in five African countries.

OBJECTIVE: To explore the experience of HIV/AIDS-related stigma for people living with HIV/AIDS (PLWA) in Lesotho, Malawi, South Africa, Swaziland, and Tanzania. DESIGN AND SAMPLE: Descriptive study using 43 focus groups (n=251 participants), which included male and female PLWA from both rural and urban areas and nurses working with PLWA. METHODS: Participants were asked to relate incidents of HIV/AIDS-related stigma that they had experienced or observed. Focus group discussions were taped, and data were content analyzed to identify examples of abuse (verbal and physical abuse and neglect) related to HIV/AIDS stigma. Data analysis also explored targets of abuse, abusers, and consequences of abuse. RESULTS: Participant reports documented extensive verbal and physical abuse and neglect or negating (disallowing of access to services and opportunities) experienced by PLWA and observed by nurses caring for them, and identified negative consequences experienced by PLWA whose HIV-positive status was disclosed to family, friends, or community members. CONCLUSIONS: Health care workers who encourage PLWA to disclose their HIV status must carefully consider the implications of encouraging disclosure in an environment with high levels of stigma, and must recognize the real possibility that PLWA may experience serious verbal and physical abuse as a consequence of disclosure.

A conceptual model of HIV/AIDS stigma from five African countries.

AIM: This paper is a report on the development of a conceptual model delineating contexts and processes of HIV/AIDS stigma as reported by persons living with HIV/AIDS and nurses from African countries. It is part of a larger study to increase understanding of HIV/AIDS stigma. BACKGROUND: Researchers have defined stigma, explored determinants and outcomes of stigma and attempted to measure its multiple dimensions. This literature is difficult to synthesize, and often does not distinguish adequately between experiences of stigma and its causes and outcomes. METHOD: Forty-three focus groups were held with persons living with HIV/AIDS and nurses in five African countries in 2004. Focus group recordings were transcribed and coded. The data were organized into a conceptual model of HIV/AIDS stigma. FINDINGS: Two components were identified in the data: contextual factors--environment, healthcare system, agents--that influence and affect stigma and the stigma process itself. The stigma process included four dimensions: triggers of stigma, stigmatizing behaviours, types of stigma and the outcomes of stigma. CONCLUSION: A conceptual model is presented that delineates the dynamic nature of stigma as reported by study participants. The model may be used to identify areas appropriate for the design and testing of stigma reduction interventions that have a goal of reducing the burden of HIV/AIDS stigma.

Urban and rural differences in HIV/AIDS stigma in five African countries.

Stigma and discrimination have been widely researched, especially within the context of health. In the context of HIV/AIDS, studies have shown that stigma variously impacts on prevention, on accessing treatment, and on care programmes. Decreasing stigma is therefore an important goal in HIV/AIDS programmes. This paper explores whether urban and rural differences existed in reported incidents of HIV stigma from five African countries. A descriptive, qualitative research design was used to explore the experience of HIV stigma of people living with HIV (PLHIV) and nurses. Focus group discussions were held with respondents to capture an emic and etic view of stigma and discrimination. The frequency of reported incidents shows that although comparable numbers of nurses and PLHIV were sampled, the PLHIV from both the urban and rural settings in all five countries conveyed more incidents of received stigma than did the nurses. The results suggest that treatment programmes and support structures need to be designed appropriately for the different settings.

"Eating plastic," "winning the lotto," "joining the www"...descriptions of HIV/AIDS in Africa.

This report is based on qualitative data gathered through a series of focus group discussions with people living with HIV or AIDS and nurses in five African countries. Participants were asked which words or phrases people use to refer to the illness and to people living with the illness. A total of 261 respondents were involved in the 40 focus group discussions, and an analysis of the data identified 290 descriptions. The descriptions were classified into 7 categories, which were (from most to least common): attributional, neutral, death-related, physical feature-related, factual statements, lingering illness-related, and common illness-related. Whereas some terms were used in more than one country, others were unique to a specific country. The descriptions show many negative labels and beliefs, but also an awareness of the devastating effects of the illness on individuals.