Anne C. Wagner

Correlates of HIV stigma in HIV-positive women

We examined the variables associated with HIV stigma in HIV-positive women currently living in Ontario, Canada. Based on previous literature, we predicted that variables of social marginalization (e.g., ethnicity, income, education), medical variables (e.g., higher CD4 count, lower viral load), and increased psychological distress would be associated with higher perceived HIV stigma among HIV-positive women. One hundred fifty-nine HIV-positive women between the ages of 18 and 52 in Ontario completed self-report measures of the aforementioned variables. Women were recruited through 28 AIDS service organizations, eight HIV clinics, and two community health centers. In multiple regression analyses, for women born in Canada, lower educational level and higher anxiety were associated with higher HIV stigma. For women born outside of Canada, having been judged by a physician in Canada for trying to become pregnant was associated with higher HIV stigma. For HIV-positive women born outside of Canada, negative judgment by a physician regarding intentions to become pregnant should be addressed to reduce perceived HIV stigma and vice versa. Health care providers should be trained in the provision of sensitive and effective health care for women living with HIV, especially when providing reproductive health care.

Health Care Provider Attitudes and Beliefs About People Living with HIV: Initial Validation of the Health Care Provider HIV/AIDS Stigma Scale (HPASS)

HIV stigma is a pressing concern for people living with HIV, and particularly when it is perpetuated by health care providers, as it may affect quality of life and access to health care services. The current study describes the development and initial validation of a contextually appropriate HIV stigma scale for health care providers in North America. A ground-up qualitative approach was used to develop the scale, and it was assessed psychometrically with health care trainees across Canada. The measure demonstrates excellent internal consistency reliability and test–retest reliability, as well as convergent and divergent validity. The study supports a tripartite model of HIV stigma consisting of stereotyping, prejudice and discrimination. The scale provides a new tool to assess HIV stigma in health care providers and can be used to inform training, intervention and self-evaluation of stigmatizing attitudes, beliefs and behaviors among providers.

Cognitive-behavioral conjoint therapy for PTSD improves various PTSD symptoms and trauma-related cognitions: Results from a randomized controlled trial.

Numerous studies document an association between posttraumatic stress disorder (PTSD) and impairments in intimate relationship functioning, and there is evidence that PTSD symptoms and associated impairments are improved by cognitive-behavioral conjoint therapy for PTSD (CBCT for PTSD; Monson & Fredman, 2012). The present study investigated changes across treatment in clinician-rated PTSD symptom clusters and patient-rated trauma-related cognitions in a randomized controlled trial comparing CBCT for PTSD with waitlist in a sample of 40 individuals with PTSD and their partners (N = 40; Monson et al., 2012). Compared with waitlist, patients who received CBCT for PTSD immediately demonstrated greater improvements in all PTSD symptom clusters, trauma-related beliefs, and guilt cognitions (Hedges gs -.33 to -1.51). Results suggest that CBCT for PTSD improves all PTSD symptom clusters and trauma-related cognitions among individuals with PTSD and further supports the value of utilizing a couple-based approach to the treatment of PTSD.

Understanding Social Factors in the Context of Trauma: Implications for Measurement and Intervention

ABSTRACT One of the most important factors predicting the presence of posttraumatic stress disorder (PTSD) after trauma exposure is social support, yet the construct is theoretically complex and remains variably defined. To better inform the trauma literature on the impact of social factors, a theoretical review of social support and PTSD was conducted, and implications for measurement and intervention are outlined. Type of trauma, sex of participant, timing of social support, and support providers are described as significant moderators of the association between social factors and PTSD. The developmental trajectory of the association between social factors and PTSD occurrence is outlined, emphasizing the positive influence of social support initially following trauma, and the deterioration effect of PTSD symptoms on social support over the longer term. Possibilities for future research and intervention at multiple levels and at different time points are described.

Examining the Evidence for Complex Posttraumatic Stress Disorder as a Clinical Diagnosis

This article examines the evidence for complex posttraumatic stress disorder (C-PTSD) as a clinical diagnosis distinct from posttraumatic stress disorder (PTSD). A brief overview of the history of the debate surrounding C-PTSD is presented. The construct validity of C-PTSD is evaluated, and the overlap among C-PTSD, PTSD, and borderline personality disorder is explored. The extent to which existing PTSD treatments reduce symptoms of C-PTSD is discussed, and the treatment outcome data underlying proposed C-PTSD treatment guidelines are reviewed. The authors explore the C-PTSD debate in light of the recent release of the Diagnostic and Statistical Manual of Mental Disorders (5th ed., American Psychiatric Association, 2013), which did not include C-PTSD as a diagnosis, and the proposed changes to the forthcoming International Classification of Diseases (11th revision), which is expected to include C-PTSD as a diagnosis (see Maercker et al., 2013). The authors maintain there is insufficient evidence to warrant the addition of a C-PTSD diagnosis or the dissemination of treatment guidelines for C-PTSD.

Examining the Traits-Desires-Intentions-Behavior (TDIB) model for fertility planning in women living with HIV in Ontario, Canada.

The objective of this study was to determine the predictors of fertility behavior (i.e., trying to become pregnant) in a large representative sample of women living with HIV of reproductive age in Ontario, Canada. The Traits-Desires-Intentions-Behavior model was used to examine the key predictors of reproductive decision making and behavior. A total of 320 women living with HIV were included in the current analysis. The women living with HIV were between the ages of 18 and 52 (mean=37.23, SD=7.53), 56.4% had at least one child living in the home, over 40% identified as being of African ethnicity, and the average time since HIV diagnosis was 10.49 years (SD=5.71). In hierarchical multilevel analysis, perceived family support for trying to become pregnant, living in a large metropolitan city (i.e., Toronto), womens fertility desires, and fertility intentions were associated with fertility behavior (χ(2)9=59.97, p<0.001). As only 10.6% of participants reported engaging in fertility-related behavior, while 57.5% intended a pregnancy in the future, identifying barriers to fertility and discrepancies between intentions and behaviors can support policy programs and assist health care providers to better facilitate the fertility goals of women living with HIV.

HIV-related stigma in pregnancy and early postpartum of mothers living with HIV in Ontario, Canada

ABSTRACT HIV-related stigma is associated with many psychological challenges; however, minimal research has explored how perceived HIV-related stigma intersects with psychosocial issues that mothers living with HIV may experience including depression, perceived stress and social isolation. The present study aims to describe the correlates and predictors of HIV-related stigma in a cohort of women living with HIV (WLWH) from across Ontario, Canada during pregnancy and early postpartum. From March 2011 to December 2012, WLWH ≥ 18 years (n = 77) completed a study instrument measuring independent variables including sociodemographic characteristics, perceived stress, depression symptoms, social isolation, social support and perceived racism in the third trimester and 3, 6 and 12 months postpartum. Multivariable linear regression was employed to explore the relationship between HIV-related stigma and multiple independent variables. HIV-related stigma generally increased from pregnancy to postpartum; however, there were no significant differences in HIV-related stigma across all study time points. In multivariable regression, depression symptoms and perceived racism were significant predictors of overall HIV-related stigma from pregnancy to postpartum. The present analysis contributes to our understanding of HIV-related stigma throughout the pregnancy–motherhood trajectory for WLWH including the interactional relationship between HIV-related stigma and other psychosocial variables, most notably, depression and racism.

Couple Treatment for Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) affects not only the people suffering from the disorder but also those surrounding them. PTSD is one of the mental health difficulties most strongly associated with relationship distress (Whisman et al. 2000); it has a strong association with a range of family problems, including mental health difficulties in partners and children (Monson et al. 2009; Renshaw et al. 2011; Taft et al. 2011). PTSD can elicit responses from friends and family that are well-meaning but may maintain the symptoms of PTSD, such as helping the individual with PTSD avoid reminders of the trauma, which may over time erode these relationships and place increased burden on family members, leading to negative mental health outcomes (Caska and Renshaw 2011). These accommodative behaviors may also reinforce avoidance associated with PTSD (Figley 1989). Consistent with research documenting that negative social interactions in the wake of trauma are among the most robust risk factors for PTSD (e.g., see Wagner et al. under review for a review), negative family interactions have been linked to poorer individual cognitive-behavioral therapy outcomes (Monson et al. 2005; Tarrier et al. 1999). Moreover, individual evidence-based treatments for PTSD do not consistently improve relational functioning (e.g., Galovski et al. 2005; Monson et al. 2012a, b, c; Lunney and Schnurr 2007). Consequently, there have been efforts to develop and test dyadic treatments that improve relational functioning and PTSD and, in some cases, also improve the health and well-being of partners. The current chapter describes different ways to conceptualize couple treatment in the case of PTSD and reviews the efficacy of these interventions.

HIV-Related Stigma and Overlapping Stigmas Towards People Living With HIV Among Health Care Trainees in Canada

HIV continues to be a stigmatized disease, despite significant advances in care and concerted effort to reduce discrimination, stereotypes, and prejudice. Living with HIV is often associated with a multitude of overlapping and intersecting experiences which can, in and of themselves, also be stigmatized, and which may exacerbate HIV-related stigma. The consequences of these stigmatizing experiences are particularly impactful when the stigmatizing individual is a health care provider, as this can influence access to and quality of care. The current study empirically investigates a model of overlapping stigmas (homophobia, racism, sexism, stigma against injection drug use and stigma against sex work) potentially held by health care provider trainees in Canada to determine how these constructs overlap and intersect, and to assess whether HIV-related stigma may have unique attributes. Understanding overlapping stigmas can help inform targeted, stigma-informed training for health care trainees in order to provide effective, compassionate care for people living with HIV.

The role of people living with HIV as patient instructors – reducing stigma and improving interest around HIV care among medical students*

ABSTRACT People living with HIV/AIDS (PHAs) are increasingly recognized as experts in HIV and their own health. We developed a simulated clinical encounter (SCE) in which medical students provided HIV pre- and post-test counselling and point-of-care HIV testing for PHAs as patient instructors (PHA-PIs) under clinical preceptor supervision. The study assessed the acceptability of this teaching tool with a focus on assessing impact on HIV-related stigma among medical students. University of Toronto pre-clerkship medical students participated in a series of SCEs facilitated by 16 PHA-PIs and 22 clinical preceptors. Pre- and post-SCE students completed the validated Health Care Provider HIV/AIDS Stigma Scale (HPASS). HPASS measures overall stigma, as well as three domains within HIV stigma: stereotyping, discrimination, and prejudice. Higher scores represented higher levels of stigma. An additional questionnaire measured comfort in providing HIV-related care. Mean scores and results of paired t-tests are presented. Post-SCE, students (n  = 62) demonstrated decreased overall stigma (68.74 vs. 61.81, p  < .001) as well as decreased stigma within each domain. Post-SCE, students (n  = 67) reported increased comfort in providing HIV-related care (10.24 vs. 18.06, p  < .001). Involving PHA-PIs reduced HIV-related stigma among medical students and increased comfort in providing HIV-related care.