Wayne T. Steward

HIV-related stigma: Adapting a theoretical framework for use in India

Stigma complicates the treatment of HIV worldwide. We examined whether a multi-component framework, initially consisting of enacted, felt normative, and internalized forms of individual stigma experiences, could be used to understand HIV-related stigma in Southern India. In Study 1, qualitative interviews with a convenience sample of 16 people living with HIV revealed instances of all three types of stigma. Experiences of discrimination (enacted stigma) were reported relatively infrequently. Rather, perceptions of high levels of stigma (felt normative stigma) motivated people to avoid disclosing their HIV status. These perceptions often were shaped by stories of discrimination against other HIV-infected individuals, which we adapted as an additional component of our framework (vicarious stigma). Participants also varied in their acceptance of HIV stigma as legitimate (internalized stigma). In Study 2, newly developed measures of the stigma components were administered in a survey to 229 people living with HIV. Findings suggested that enacted and vicarious stigma influenced felt normative stigma; that enacted, felt normative, and internalized stigma were associated with higher levels of depression; and that the associations of depression with felt normative and internalized forms of stigma were mediated by the use of coping strategies designed to avoid disclosure of ones HIV serostatus.

Effects of a behavioral intervention to reduce risk of transmission among people living with HIV: The Healthy Living Project randomized controlled study

Context:The US Centers for Disease Control and Prevention (CDC) strongly recommend comprehensive risk counceling and services for people living with HIV (PLH); yet, there are no evidence-based counseling protocols. Objective:To examine the effect of a 15-session, individually delivered, cognitive behavioral intervention on a diverse sample of PLH at risk of transmitting to others. Design:This was a multisite, 2-group, randomized, controlled trial. Participants:Nine hundred thirty-six HIV-infected participants considered to be at risk of transmitting HIV of 3818 persons screened were randomized into the trial. Participants were recruited in Los Angeles, Milwaukee, New York, and San Francisco. Intervention:Fifteen 90-minute individually delivered intervention sessions were divided into 3 modules: stress, coping, and adjustment; safer behaviors; and health behaviors. The control group received no intervention until the trial was completed. Both groups completed follow-up assessments at 5, 10, 15, 20, and 25 months after randomization. Main Outcome Measure:Transmission risk, as measured by the number of unprotected sexual risk acts with persons of HIV-negative or unknown status, was the main outcome measure. Results:Overall, a significance difference in mean transmission risk acts was shown between the intervention and control arms over 5 to 25 months (χ2 = 16.0, degrees of freedom = 5; P = 0.007). The greatest reduction occurred at the 20-month follow-up, with a 36% reduction in the intervention group compared with the control group. Conclusion:Cognitive behavioral intervention programs can effectively reduce the potential of HIV transmission to others among PLH who report significant transmission risk behavior.

The impact of universal access to antiretroviral therapy on HIV stigma in Botswana.

OBJECTIVES We sought to examine the impact of treatment access on HIV stigma in Botswana 3 years after the introduction of a national program of universal access to antiretroviral therapy. METHODS We studied the prevalence and correlates of HIV stigma in a population-based study of 1268 adults in Botswana in 2004. We used multivariate logistic regression to assess correlates of stigmatizing attitudes and a new measure, anticipated HIV stigma. RESULTS Overall, 38% of participants had at least 1 stigmatizing attitude: 23% would not buy food from a shopkeeper with HIV; 5% would not care for a relative with HIV. Seventy percent reported at least 1 measure of anticipated stigma: 54% anticipated ostracism after testing positive for HIV, and 31% anticipated mistreatment at work. Perceived access to antiretroviral therapy was strongly and independently associated with decreased odds of holding stigmatizing attitudes (adjusted odds ratio [AOR] = 0.42; 95% confidence interval [CI] = 0.24, 0.74) and of anticipated stigma (AOR = 0.09; 95% CI = 0.03, 0.30). CONCLUSIONS Our findings suggest that antiretroviral therapy access may be a factor in reducing HIV stigma. Nevertheless, the persistence of stigmatizing attitudes and significant anticipated stigma suggest that HIV stigma must be a target for ongoing intervention.

Correlates of suicidal ideation among HIV-positive persons.

Objectives:The present investigation sought to determine the extent to which demographic characteristics, illness-related burdens, alcohol and other substance use, and psychosocial factors are independently associated with suicidal ideation in HIV-positive individuals. Design:HIV-positive individuals in four US cities (San Francisco, Los Angeles, Milwaukee, and New York City) were screened between July 2000 and January 2002 for recruitment into a randomized behavioral prevention trial. Utilizing data from this screening visit, rates and correlates of suicidal ideation were examined in a diverse sample of 2909 HIV-positive individuals. Methods:Using binary logistic regression study sites, demographic characteristics, illness-related burdens, alcohol and substance use, and psychosocial factors were entered as predictors of suicidal ideation. This cross-sectional model thus examined the independent effects of each factor. Results:Approximately one-fifth (19%) of participants reported thoughts of suicide in the past week. We observed that participants who were not heterosexual, rated HIV-related symptoms and medication side effects as more severe, reported regular marijuana use, and described elevated affective symptoms of depression were those who were more likely to report suicidal ideation. Conversely, participants who identified as Hispanic/Latino, individuals in a primary romantic relationship, and those who reported greater self-efficacy for coping were less likely to report suicidal ideation. Conclusion:Suicidal ideation among HIV-positive individuals is relatively common and is associated with multiple factors. These independent correlates may assist with identifying HIV-positive individuals who are at increased risk of suicidal ideation so that they may be assessed regularly and referred for psychological treatment when appropriate.

Psychiatric risk factors for HIV disease progression: the role of inconsistent patterns of antiretroviral therapy utilization.

Background:In the era of antiretroviral therapy (ART), depression and substance use predict hastened HIV disease progression, but the underlying biological or behavioral mechanisms that explain these effects are not fully understood. Methods:Using outcome data from 603 participants enrolled in a randomized controlled trial of a behavioral intervention, binary logistic and linear regression were employed to examine whether inconsistent patterns of ART utilization partially mediated the effects of depression and substance use on higher HIV viral load over a 25-month follow-up. Results:Elevated affective symptoms of depression independently predicted ART discontinuation [adjusted odds ratio = 1.39, 95% confidence interval (CI) = 1.08 to 1.78], and use of stimulants at least weekly independently predicted intermittent ART utilization (adjusted odds ratio = 2.62, 95% CI = 1.45 to 4.73). After controlling for the average self-reported percentage of ART doses taken and baseline T-helper (CD4+) count, elevated depressive symptoms predicted a 50% higher mean viral load, and weekly stimulant use predicted a 137% higher mean viral load. These effects became nonsignificant after accounting for inconsistent patterns of ART utilization, providing evidence of partial mediation. Conclusions:Inconsistent patterns of ART utilization may partially explain the effects of depression and stimulant use on hastened HIV disease progression.

Missed opportunities: prevention with HIV-infected patients in clinical care settings.

Objective:To assess current practices related to prevention with HIV-positive patients in Ryan White–funded primary care settings and the barriers to providing such services. Method:Exit surveys about HIV prevention services were conducted with 618 HIV-infected patients at 16 primary HIV care clinics receiving Ryan White CARE Act funding. To place the exit survey findings in context, qualitative in-depth interviews were conducted with 16 clinic administrators, 32 primary care providers, 32 support service providers, and 64 patients. Results:One quarter of patients reported having had a general discussion of “safer sex and ways to prevent transmission to others” during that day’s primary care visit. However, only 6% reported discussing specific sexual activities. HIV prevention counseling was less common than counseling for adherence to antiretroviral therapy, emotional issues, and diet and nutrition (P < 0.001). Patients in clinics with established procedures for HIV prevention counseling were significantly more likely to report receiving such services (odds ratio = 2.17). Qualitative interviews identified barriers to providing prevention services as lack of time, training, funding for staffing, and providers’ understanding of their roles and responsibility. Conclusions:HIV prevention counseling is not routine in most clinics, and the low frequency of such services represents missed opportunities for HIV prevention.

A Qualitative Study of Provider Thoughts on Implementing Pre-Exposure Prophylaxis (PrEP) in Clinical Settings to Prevent HIV Infection

Background A recent clinical trial demonstrated that a daily dose tenofovir disoproxil fumarate and emtricitabrine (TDF-FTC) can reduce HIV acquisition among men who have sex with men (MSM) and transgender (TG) women by 44%, and up to 90% if taken daily. We explored how medical and service providers understand research results and plan to develop clinical protocols to prescribe, support and monitor adherence for patients on PrEP in the United States. Methods Using referrals from our community collaborators and snowball sampling, we recruited 22 healthcare providers in San Francisco, Oakland, and Los Angeles for in-depth interviews from May-December 2011. The providers included primary care physicians seeing high numbers of MSM and TG women, HIV specialists, community health clinic providers, and public health officials. We analyzed interviews thematically to produce recommendations for setting policy around implementing PrEP. Interview topics included: assessing clinician impressions of PrEP and CDC guidance, considerations of cost, office capacity, dosing schedules, and following patients over time. Results Little or no demand for PrEP from patients was reported at the time of the interviews. Providers did not agree on the most appropriate patients for PrEP and believed that current models of care, which do not involve routine frequent office visits, were not well suited for prescribing PrEP. Providers detailed the need to build capacity and were concerned about monitoring side effects and adherence. PrEP was seen as potentially having impact on the epidemic but providers also noted that community education campaigns needed to be tailored to effectively reach specific vulnerable populations. Conclusions While PrEP may be a novel and clinically compelling prevention intervention for MSM and TG women, it raises a number of important implementation challenges that would need to be addressed. Nonetheless, most providers expressed optimism that they eventually could prescribe and monitor PrEP in their practice.

Assessment of Stigma Towards Homosexuality in China: A Study of Men Who Have Sex with Men

Previous research has documented the deleterious impact of homosexuality stigma on HIV sexual risk behavior among men who have sex with men (MSM) and the vulnerability of this group in China for HIV acquisition. Factor analysis of 10 survey items from 477 MSM from Shanghai yielded two factors: Perceived stigma assessed participants’ impressions of the degree of societal stigmatization of homosexuals whereas enacted stigma measured direct personal experiences of stigmatizing behaviors. Enacted stigma exhibited satisfactory internal reliability and was associated with HIV sexual risk behavior. Further research is needed to refine perceived and other stigma constructs for Chinese MSM.

Predicting HIV transmission risk among HIV-infected men who have sex with men: findings from the healthy living project.

Objective:To examine the predictors of transmission risk among HIV-infected men who have sex with men (MSM) in 4 US cities. Method:Individual computer-assisted interviews assessing psychologic measures and sexual behavior with the 5 most recent male and female partners were conducted with a diverse sample of 1910 HIV-infected MSM recruited from community and clinic settings in San Francisco, New York, Los Angeles, and Milwaukee. Transmission-risk events were defined as unprotected vaginal or anal sex with a partner who was HIV negative or of unknown status. Results:A small but not insignificant proportion of MSM (12.7%) reported at least 1 transmission-risk event in the previous 3 months, with 57% of those events taking place with casual as opposed to steady partners. Multivariate predictors of transmission risk with casual partners were stimulant (eg, crystal methamphetamine) and other drug use, having low coping self-efficacy, and not having disclosed ones HIV serostatus to all partners. Stimulant use and failing to disclosing ones serostatus to all partners were associated with risk in primary relationships. Conclusions:Responding to HIV transmission risk in MSM requires different strategies for primary and casual partners.

Social Discrimination, Concurrent Sexual Partnerships, and HIV Risk Among Men Who have Sex with Men in Shanghai, China

We examined the potential mediating role of sex partner concurrency in explaining associations between experiences of homophobia and financial hardship and HIV risk behavior among a sample of 477 men who have sex with men (MSM) recruited in Shanghai, China from 2004 to 2005. We found significant positive direct associations of experiences of homophobia and financial hardship with having unprotected anal sex with men. These associations were not mediated by male partner concurrency. However, male partner concurrency had a direct effect on having unprotected anal sex with men. Male and female partner concurrency did not mediate the significant association between experiences of homophobia and having unprotected anal/vaginal sex with both men and women, but was positively associated with having unprotected anal/vaginal sex with both men and women. These results suggest that homophobia, financial hardship, and sex partner concurrency should be addressed to help reduce sexual risk for HIV among MSM in China.