Financial and Food Insecurity are Primary Challenges to Breastfeeding for Women Living with HIV in Western Kenya: A Longitudinal Qualitative Investigation.

Exclusive breastfeeding for the first 6 months and continued breastfeeding for 24 months or longer is recommended for all mothers world-wide, including women living with HIV (WLWH). Given evidence of suboptimal infant feeding and the need to understand context specific barriers, we explored experiences of perinatal WLWH in Kisumu, Kenya. We applied a longitudinal qualitative approach (4 in-depth interviews) with 30 women from pregnancy to 14-18 months postpartum. Cross-sectional profiling led to a narrative description of infant feeding across time. The majority of women breastfed exclusively for 6 months and weaned by 18 months. Severe financial and food insecurity were primary challenges as women worked through when/how to breastfeed or stop breastfeeding in the setting of multiple competing priorities/pressures across time. Financial and food support and increased support for breastfeeding beyond 18 months have the potential to reduce women's stress and uncertainty associated with infant feeding as well as optimize infant health and nutrition in this setting.

RESUMEN: Se recomienda la lactancia materna exclusiva durante los primeros 6 meses y la continuación de la lactancia durante 24 meses o más para todas las madres en todo el mundo, incluidas las mujeres que viven con el VIH (WLWH). Debido a la evidencia de alimentación infantil subóptima y la necesidad de comprender las barreras específicas del contexto, exploramos las experiencias de WLWH perinatal en Kisumu, Kenia. Aplicamos un enfoque cualitativo longitudinal (4 entrevistas en profundidad) con 30 mujeres desde el embarazo hasta los 14-18 meses posparto. El perfil transversal resultó en una descripción narrativa de la alimentación infantil a través del tiempo. La mayoría de las mujeres amamantaron exclusivamente durante 6 meses y dejó de amamantar a los 18 meses. La grave inseguridad financiera y alimentaria fueron los principales desafíos cuando las mujeres analizaban cuándo y cómo amamantar o dejar de amamantar en el contexto de múltiples prioridades y presiones en competencia a través del tiempo. El apoyo financiero y alimentario y un mayor apoyo para la lactancia más allá de los 18 meses tienen el potencial de reducir el estrés y la incertidumbre de las mujeres asociados con la alimentación infantil, así como optimizar la salud y la nutrición infantil en este entorno.

Societal stigma and mistreatment in healthcare among gender minority people: a cross-sectional study.

BACKGROUND: Gender minority (GM; individuals whose gender is not aligned with that traditionally associated with the sex that was assigned to them at birth) people have widely reported mistreatment in healthcare settings. Mistreatment is enacted by individuals within society who hold stigmatizing beliefs. However, the relationship between healthcare mistreatment and societal stigma (i.e., the degree to which society disapproves of GM people) is unclear and not measured consistently. METHODS: We analyzed data from 2,031 GM participants in The Population Research in Identity and Disparities for Equality (PRIDE) Study's 2019 Annual Questionnaire to determine whether societal stigma was associated with participants' past-year reports of mistreatment (defined as denial of healthcare services and/or lower quality care) in medical or mental healthcare settings. We created a proxy measure of societal stigma by incorporating variables validated in existing literature. Participants reported whether they had experienced mistreatment in medical and mental health settings independently. RESULTS: Healthcare denial and/or lower quality care during the past year was reported by 18.8% of our sample for medical settings and 12.5% for mental health settings. We found no associations between the societal stigma variables and past-year reports of healthcare denial and/or lower quality care in medical or mental healthcare settings. CONCLUSIONS: Although a high proportion of GM people reported past-year healthcare mistreatment in both medical and mental health settings, mistreatment had no relationship with societal stigma. Factors other than societal stigma may be more important predictors of healthcare mistreatment, such as healthcare workers' knowledge of and attitudes toward GM people. However, other measures of societal stigma, or different types of mistreatment, may show stronger associations. Identifying key factors that contribute to mistreatment can serve as targets for intervention in communities and healthcare settings.

Prevalence and correlates of methamphetamine use in transitional age youth experiencing homelessness or housing instability in San Francisco, CA.

INTRODUCTION: Substance use, including methamphetamine use, is a contributing factor in HIV acquisition and treatment. Stimulant use is linked to mental health yet there is limited data from youth in community-based settings. DESIGN: One hundred marginally housed or homeless transitional age youth (TAY) were recruited at Larkin Street Youth Services and completed a survey on mental health and substance use. METHODS: We conducted secondary data analysis using multivariable logistic regression models to identify the correlates of methamphetamine use among TAY. RESULTS: The participants' mean age was 22. Of those who reported methamphetamine use in the past 3 months, 64% were Gay, Bisexual, or Pansexual. Factors independently associated with methamphetamine use were; living with HIV (adjusted odds ratio [aOR] = 3.18, 95% CI = 1.11-9.15), depressive symptoms (aOR = 6.02, 95% CI = 1.46-24.78), symptoms of PTSD (aOR = 13.38, 95% CI = 1.59-112.73), polysubstance use in the past 3 months (aOR = 50.02, 95% CI = 9.72-257.46) and a history of injection drug use (aOR = 8.38, 95% CI = 1.87-37.53). CONCLUSIONS: Results from this study suggest a need to develop, adapt, and rapidly implement comprehensive interventions that address the combined epidemics of substance use, HIV, and mental health among TAY. CLINICAL RELEVANCE: This article examines factors associated with methamphetamine use among transitional age youth (TAY) experiencing homelessness or housing instability. Several factors were associated with use, including depression, PTSD, HIV status, polysubstance use, and injection drug use. These findings highlight the need for nurses to assess for methamphetamine use among youth as well as associated mental health and physical health problems. Nurses should link TAY who are using methamphetamine to evidence-based treatment programs to address substance use and comorbid conditions.

Stressors in health care and their association to symptoms experienced by gender diverse people.

OBJECTIVES: Many individuals whose gender does not align with the sex they were assigned at birth (gender diverse [GD] people) report stressful health care encounters. We examined the relationship of these stressors to symptoms of emotional distress and impaired physical functioning among GD people. STUDY DESIGN: This study was conducted using a cross-sectional design with data from the 2015 United States Transgender Survey. METHODS: Composite metrics of health care stressors and physical impairments were developed, and the Kessler Psychological Distress Scale (K-6) provided a measure of emotional distress. Linear and logistic regression were used to analyze the aims. RESULTS: A total of 22,705 participants from diverse gender identity subgroups were included. Participants who experienced at least one stressor in health care during the past 12 months had more symptoms of emotional distress (ß = 0.14, P < .001) and 85% greater odds of having a physical impairment (odds ratio = 1.85, P < .001). Transgender men exposed to stressors were more likely than transgender women to experience emotional distress and have a physical impairment, with other gender identity subgroups reporting less distress. Black participants exposed to stressful encounters reported more symptoms of emotional distress than White participants. CONCLUSIONS: The results suggest that stressful encounters in health care are associated with symptoms of emotional distress and greater odds of physical impairment for GD people, with transgender men and Black individuals being at greatest risk of emotional distress. The findings indicate the need for assessment of factors that contribute to discriminatory or biased health care for GD people, education of health care workers, and support for GD people to reduce their risk of stressor-related symptoms.

Trauma-Informed Home Visiting Models in Public Health Nursing: An Evidence-Based Approach.

Traumatic experiences can have significant health effects, particularly when they are experienced during childhood. Structural determinants of health including environmental disasters and limited access to mental health services and affordable housing can contribute additional stress for parents with a personal history of childhood adversity. These factors can directly affect their children, contributing to intergenerational trauma. Pregnant people and families with young children are often referred to public health nursing maternal and child home visiting (HV) programs when there are concerns about historical or evolving childhood trauma. The strict eligibility and participation requirements of existing evidence-based maternal and child HV programs can exclude families that have experienced or are experiencing childhood trauma and its effects and can limit innovation by public health nurses, a hallmark of the field. Therefore, we advocate and describe the implementation of the Trauma Informed Approach in Public Health Nursing (TIA PHN) model, which incorporates a trauma-informed approach into a traditional maternal and child HV program in 3 California counties. TIA PHN, which began enrollment in March 2021, involves public health nurses and community health workers and integrates program evaluations in pursuit of evidence-based status. (Am J Public Health. 2022;112(S3):S298-S305. https://doi.org/10.2105/AJPH.2022.306737).

Climate Change, Public Health, Health Policy, and Nurses Training.

There are few educational programs in the United States that have a primary focus on preparing nurses to engage in all levels of public health, health policy, and climate change. The United Nations sustainability development goals (SDG) and the Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (2021) report underscored the importance of key stakeholders, including nurses, engaging in advocacy and policy to promote health equity. We discuss the role of nursing at the intersection of public health, policy, climate change, and the SDG. We also discuss the history and merger of the University of California San Francisco (UCSF) School of Nursing public health and health policy specialties, a significant innovation in our effort to promote health equity. We provide a brief overview of the redesigning of our curriculum that meets the needs of today's learners by including content on climate change, data analytics, and racial, social, and environmental justice. Finally, we emphasize the need to train the next cadre of nurses interested in careers in public health and health policy for us to meet the challenges facing our communities. (Am J Public Health. 2022;112(S3):S321-S327. https://doi.org/10.2105/AJPH.2022.306826).

Interventions for addressing trauma among people with HIV: a narrative review.

Traumatic experiences are disproportionately prevalent among people with HIV and adversely affect HIV-related health outcomes. As part of a national cooperative agreement funded by the Health Resources and Services Administration's HIV/AIDS Bureau, we searched the literature for interventions designed to address trauma among people with HIV in the U.S. Our search yielded 22 articles on 14 studies that fell into five intervention categories: expressive writing, prolonged exposure therapy, coping skills, cognitive-behavioral approaches integrated with other methods, and trauma-informed care. Thematic elements among the interventions included adaptating existing interventions for subpopulations with a high burden of trauma and HIV, such as transgender women and racial/ethnic minorities; addressing comorbid substance use disorders; and implementing organization-wide trauma-informed care approaches. Few studies measured the effect of the interventions on HIV-related health outcomes. To address the intersecting epidemics of HIV and trauma, it is critical to continue developing, piloting, and evaluating trauma interventions for people with HIV, with the goal of wide-scale replication of effective interventions in HIV settings.

Working status and seasonal meteorological conditions predict physical activity levels in people living with HIV.

Little is known about how demographic, employment and meteorological factors impact physical activity. We conducted an analysis to explore these associations from participants (N = 447) from six cities in the United States and matched their activity data with abstracted local meteorological data from National Oceanic and Atmospheric Administration (NOAA) weather reports. Participants were purposively recruited in 3-month blocks, from December 2015 to October 2017, to reflect physical activity engagement across the seasons. We calculated total physical activity (minutes/week) based on 7-day physical activity recall. Mild correlations were observed between meteorological factors and correlated with lower physical activity. Participants were least active in autumn (Median = 220 min/week) and most active in spring (Median = 375 min/week). In addition to level of education and total hours of work, maximum temperature, relative humidity, heating degree day, precipitation and sunset time together explained 17.6% of variance in total physical activity. Programs assisting in employment for PLHIV and those that promote indoor physical activity during more strenuous seasons are needed. Additional research to better understand the selection, preferences, and impact of indoor environments on physical activity is warranted.

Antiracist symptom science: A call to action and path forward.

Nurse scientists recognize the experience of racism as a driving force behind health. However, symptom science, a pillar of nursing, has rarely considered contributions of racism. Our objective is to describe findings within symptom science research related to racial disparities and/or experiences of racism and to promote antiracist symptom science within nursing research. In this manuscript, we use an antiracist lens to review a predominant symptom science theory and literature in three areas of symptom science research-oncology, mental health, and perinatal health. Finally, we make recommendations for increasing antiracist research in symptom science by altering (a) research questions, (b) recruitment methods, (c) study design, (d) data analysis, and (e) dissemination of findings. Traditionally, symptom science focuses on individual level factors rather than broader contexts driving symptom experience and management. We urge symptom science researchers to embrace antiracism by designing research with the specific intent of dismantling racism at multiple levels.

Substance use experiences of HIV-positive and HIV-negative black, non-hispanic men who have sex with men (msm) ages 18-34 in the Bay Area: A qualitative narrative perspective.

OBJECTIVE: Young Black men who have sex with men (MSM) represent the majority of individuals with new HIV infections in the U.S. Substance use is related to risk and acquisition t of HIV. The purpose of this study was to explore the perceptions and experiences about the role substance use plays in the lives HIV-positive and HIV-negative young Black MSM between the ages of 18-34. METHODS: Using a qualitative, narrative perspective, we recruited and then interviewed participants in partnership with AIDS Service Organizations. Narrative and thematic analysis was used to analyze these Black men's personal stories with harm reduction used as the conceptual approach. RESULTS: Nine HIV-positive and 3 HIV-negative participants(n = 12) shared stories about their own personal experiences with family relationships and substance use. Themes related to family included early exposure and initiation of substance use, substance use as a response to stigma around sexual orientation, kicked out of house, asked to leave or left home so they could be themselves and perceived benefits and advantages of methamphetamine. CONCLUSIONS: The participants are subjected to adverse and stressful childhood experiences. These are important stories to understand if we expect to mount an adequate response, utilizing harm reduction, to the growing number of young Black MSM at-risk for HIV.

Implementation Science Protocol: evaluating evidence-informed interventions to improve care for people with HIV seen in Ryan White HIV/AIDS program settings.

In 2017, the Health Resources and Services Administration's HIV/AIDS Bureau funded an Evaluation Center (EC) and a Coordinating Center for Technical Assistance (CCTA) to oversee the rapid implementation of 11 evidence-informed interventions at 26 HIV care and treatment providers across the U.S. This initiative aims to address persistent gaps in HIV-related health outcomes emerging from social determinants of health that negatively impact access to and retention in care. The EC adapted the Conceptual Model of Implementation Research to develop a Hybrid Type III, multi-site mixed-methods evaluation, described in this paper. The results of the evaluation will describe strategies associated with uptake, implementation outcomes, as well as HIV-related health outcomes for clients engaged in the evidence-informed interventions. This approach will allow us to understand in detail the processes that sites undergo to implement these important intervention strategies for high priority populations.

Social media use as a predictor of higher body mass index in persons living with HIV.

Social media tools have been touted as an approach to bring more democratic communication to health care. We conducted a multi-site cross-sectional study among persons living with HIV (PLWH) to desrcibe technology use among PLWH in the US and the association between social media use and body-mass index (BMI). Our primary predictor variable was social media use. Our primary outcome was BMI measured through height and weight. Descriptive statistics were used to describe the demographic profiles of the study participants and linear regression models were used to analyze associations between the outcome and predictor variables controlling for demographic characteristics. Study participants (N = 606) across 6 study sites in the United States were predominately 50-74 years old (67%). Thirty-three percent of study participants had a normal weight (BMI 18.5-25), 33% were overweight (BMI 25-30), and 32% were obese (BMI > 30). Participants used several social media sites with Facebook (45.6%) predominating. Social media use was associated with higher BMI in study participants (p < .001) and this effect persisted, although not as strongly, when limiting the analysis to those who only those who used Facebook (p = .03). Further consideration of social factors that can be ameliorated to improve health outcomes is timely and needed.

HPV vaccine promotion: Snapshot of two health departments during the COVID-19 pandemic.

The COVID-19 pandemic has impacted routine health care services including immunization delivery. The most common sexually transmitted infection in the United States is the human papillomavirus (HPV), and its sequelae may be prevented by vaccination. Sequelae that can develop if one's immune system is not able to clear the infection include warts, precancerous lesions, and cancer. The American College of Obstetricians & Gynecologists (ACOG) reports almost everyone who is sexually active will encounter the virus at some time during their life. Most of the estimated 79 million infections occur among people who are in their late teens or early 20s. Since 2006, there has been a vaccine available to prevent HPV infections in both males and females; however, administration of this vaccine has only been about half the rate of other vaccines and vaccine hesitancy may play a role. Public health nurses are vital in providing accurate and nonjudgmental vaccine education to their clients, especially unaccompanied minors seeking care in public health department clinics. This paper will explore the recommendations for providing this vaccine as well as a snapshot of current practice in two health departments in the Southeast region of the United States during the COVID-19 pandemic.

Ending intimate partner violence among women living with HIV: How attachment and HIV stigma inform understanding and intervention.

This mixed-methods, exploratory study examined why women living with HIV (WLHIV) stay in intimate partner violence (IPV) relationships and what helps end IPV in their lives. WLHIV (n = 108) who experienced IPV and were patients at two HIV primary care clinics in San Francisco completed quantitative surveys; 15 participants also completed a qualitative interview. Qualitative data showed HIV stigma was the most cited reason for staying in an IPV relationship, followed by substance use, and then by themes of attachment insecurity. Quantitative data indicated that most participants accessed HIV services and rated them as more helpful than other community resources to end IPV in their lives. Enduring attachment relationships with HIV medical and social service providers and their attachment-enhancing actions and attributes were critical to participants addressing IPV and coping with HIV stigma. This study highlights the important role that HIV providers and clinics can play in addressing IPV among WLHIV.

Use of technology for delivery of mental health and substance use services to youth living with HIV: a mixed-methods perspective.

Disparities in HIV treatment outcomes among youth living with HIV (YLWH) present a challenge for ending the HIV epidemic. Antiretroviral therapy (ART) adherence can be impacted by comorbidities such as mental health and substance use. Technology use has shown promise in increasing access to mental health and substance use services. Using a mixed-methods approach, we conducted formative research to describe the relationship between mental health, substance use, and medication adherence in 18-29 year-old YLWH, and explored technology use as an approach to supporting these services. Among 101 YLWH, ART adherence was significantly negatively associated with mental health measures such as depression, trauma, and adverse childhood experiences and marijuana and stimulants use. Depression had the highest level of relative importance in its association with ART adherence. During in-depth interviews with 29 participants, barriers to and facilitators of accessing and maintaining mental health services were identified. Most participants favored technology use for mental health and substance use service delivery, including videoconferencing with a counselor. Provision of ongoing mental health and substance use treatment is an important mechanism to achieving HIV treatment engagement. Technology, particularly videoconferencing, may have the capacity to overcome many barriers to care by increasing accessibility of these services.

Play provides social connection for older adults with serious mental illness: A grounded theory analysis of a 10-week exergame intervention.

Introduction: The number of older adults with serious mental illness (SMI) is predicted to reach 15 million by 2030. Social isolation is known to contribute to morbidity and mortality, and those with SMI experience more social isolation than older adults in the general population. Social isolation in these older adults is complex and involves factors including organic psychopathology, effects of medications and/or other substances, medical co-morbidity, disability, and social stigma. The burgeoning field of inquiry of exergames, which are video games with gestural interfaces, for older adults has found that they are safe, effective, enjoyable, and may decrease social isolation. This qualitative study was conducted to gain insight into the effects of group exergame play on the psychosocial wellbeing of older adults with SMI.Methods: We explored the psychosocial effects of a 10-week group exergame program for 16 older adults with SMI using grounded theory methodology within a symbolic interactionist framework.Results: Participants experienced positive social contact, engaged in social attunement, and expressed motivation to take risks and face problem-solving and physical challenges. Two interrelated concepts emerged from the integrated data: Social connectedness and competence. The theoretical construct that was abducted from these concepts was that play and playfulness were the vehicle for many interacting social processes to take place.Conclusion: Group play through exergames for older adults with SMI may promote recovery and healthy aging by increasing social integration, improving self-efficacy, and promoting physical health through exercise.

Trauma, substance use, and mental health symptoms in transitional age youth experiencing homelessness.

OBJECTIVE: This descriptive study examined the prevalence and correlates of trauma, substance use, and mental health symptoms in homeless transitional age youth (TAY) in San Francisco. DESIGN & SAMPLE: One hundred homeless TAY were recruited from a community-based organization to complete a survey on trauma, mental health symptoms, and substance use. MEASUREMENTS: We used these measures: National Institute on Drug Abuse (NIDA)-Modified Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) for frequency and risk level of substance use; the 10-item Adverse Childhood Experiences (ACEs) for prevalence of trauma; the Post-traumatic Stress Disorder Checklist for DSM-5 for post-traumatic stress disorder (PTSD) symptoms; Center for Epidemiologic Studies Depression Scale for depression symptoms; and Generalized Anxiety Disorder 7-item for anxiety symptoms. RESULTS: Almost all (n = 98) participants experienced at least one ACE during childhood, and 77% experienced four or more. Most participants (80%) reached the diagnostic threshold for PTSD, 74% for depression, and 51% for moderate anxiety. Symptoms of PTSD, anxiety, and depression were all significantly correlated with use of opioids and stimulants. CONCLUSION: Trauma, and co-occurring substance use and mental health problems are prevalent among homeless TAY. Individual- and community-level interventions are needed to address and improve the health of this population.

The Relationship Between Physical Activity and Cardiorespiratory Fitness Among People Living With Human Immunodeficiency Virus Throughout the Life Span.

BACKGROUND: People living with human immunodeficiency virus (PLHIV) are at an increased risk for developing cardiovascular disease (CVD). Physical activity and cardiorespiratory fitness in PLHIV are poorly understood. OBJECTIVE: The aims of this study were to describe physical activity and cardiorespiratory fitness by sex and age and to examine the association between physical activity and cardiorespiratory fitness in PLHIV, controlling for covariates. METHODS: Seven hundred two PLHIV participated in a cross-sectional study and completed validated measures of self-reported physical activity (7-day Physical Activity Recall) and cardiorespiratory fitness (6-minute walk test). Participants were recruited from 7 diverse sites in the United States and Thailand, and data were analyzed using descriptive statistics and multiple regression to examine the relationship between physical activity and cardiorespiratory fitness. RESULTS: On average, participants self-reported engaging in 115 minutes of, mostly light (75%), physical activity. Men reported twice the amount of physical activity as women (155 vs 73 minutes, P = .01). Participants' ability to achieve their predicted 6-minute walk test distances was similar between men (68%) and women (69%) (P > .01). For women, vigorous physical activity was associated with a 6.6% increase in cardiorespiratory fitness and being temporarily unemployed was associated with an 18% decline in cardiorespiratory fitness. Cardiorespiratory fitness increased with age (P < .01). CONCLUSIONS: Weekly physical activity of people living with human immunodeficiency virus averaged 85 minutes of mostly light activity, well below the recommended 150 minutes of moderate activity. Vigorous physical activity was associated with improved cardiorespiratory fitness in women, but not men. Although PLHIV would benefit from interventions to increase physical activity, our data suggest a need to develop sex-specific physical activity strategies.

"Thoughts Can Kill You": Characterization of Mental Health Symptoms by Ugandan Grandparent-Caregivers in the HIV/AIDS Era.

Studies of caregiving provided to HIV/AIDS orphans by sub-Saharan African grandparents have found that it has physical, financial, and emotional consequences. Our study extended this research by identifying and characterizing the symptoms experienced by Ugandan grandparent- caregivers, particularly as related to the caregiving role, loss and grief. Grounded theory methodology was used to conduct and analyze audio-recorded, semi-structured interviews with 32 grandparents. Findings revealed a cluster of biopsychosocial distress symptoms, especially anguish (driven by traumatic anxiety and disbelief), depression, and somatic symptoms that were linked primarily to psychological distress. The impact of cultural practices and beliefs on these symptoms was also identified. Results have implications for public health, research, and policy changes needed to alleviate symptoms of biopsychosocial distress among Uganda grandparent-caregivers.

A qualitative description of service providers' experiences of ethical issues in HIV care.

BACKGROUND: Managing HIV treatment is a complex multi-dimensional task because of a combination of factors such as stigma and discrimination of some populations who frequently get infected with HIV. In addition, patient-provider encounters have become increasingly multicultural, making effective communication and provision of ethically sound care a challenge. PURPOSE: This article explores ethical issues that health service providers in the United States and Botswana encountered in their interaction with patients in HIV care. RESEARCH DESIGN: A descriptive qualitative design was used to collect data from health service providers and patients using focused group discussions. This article is based on responses from health service providers only. PARTICIPANTS AND CONTEXT: This article is based on 11 focused group discussions with a total sample of 71 service providers in seven US sites and one Botswana site. ETHICAL CONSIDERATIONS: Ethical review boards at all the study sites reviewed the study protocol and approved it. Ethical review boards of the study's coordinating centers, Rutgers University and the University of California at San Francisco, also approved it. The study participants provided a written informed consent to participate. FINDINGS: HIV service providers encountered ethical challenges in all the four Beauchamp and Childress' biomedical ethics of respect for patients' autonomy, beneficence, justice, and nonmaleficence. DISCUSSION: The finding that HIV service providers encounter ethical challenges in their interaction with patients is supported by prior studies. The ethical challenges are particularly prominent in multicultural care and resource-constrained care environments. CONCLUSION: Provision of HIV care is fraught with ethical challenges that tend to pose different issues depending on a given care environment. It is important that strong partnerships are developed among key stakeholders in HIV care. In addition, health service providers need to be provided with resources so they can provide quality and ethically sound care.