HIV and tuberculosis: the construction and management of double stigma

Mitigation of the tuberculosis (TB) and HIV syndemic is undermined by critical clinical, operational and social challenges of which the social aspects have been least explored. This paper examines the lived experience of TB disease and HIV from the perspective of affected individuals to analyze how they may think about their dual illness; how they understand their illness with TB in relation to HIV, and vice versa; and how they characterize their (stigmatized) experiences in the context of their perceptions and identities. From February-August 2009, qualitative, semi-structured interviews were conducted with 40 adults with HIV and TB disease at three ambulatory clinics in KwaZulu-Natal, South Africa. Subjective meanings of illness experience were analyzed using modified grounded-theory. Emergent themes on illness perception and disclosure revealed how patients constructed dichotomous identities associated with TB and HIV through social constructs of moral susceptibility and (im)permanence. Each identity was associated with relatively disparate degrees of stigma as a product of labeling, negative stereotyping and discrimination. HIV bore the least desirable identity and invoked the greatest stigma. However, the confluence of the two epidemics rendered TB symbolic and symptomatic of HIV, and enhanced the visibility of AIDS. Dual illness thus introduced a paradox to patients' identity constructions, and produced a unique, overlapping double stigma. This facilitated new forms of stigma against TB, and aggravated existing stigma against HIV. It also conferred visibility to some forms of extra-pulmonary TB. Patients managed their double stigmas through novel forms of information sharing that relied on segregating their dual illness identities. Patients deflected the dominant stigma of HIV through concurrent processes of HIV 'othering' - their symbolic distancing from persons affected by HIV, and 'covering' - their selective disclosure of illness (and identity associated) with TB over that of HIV. Findings call for greater consideration to the complex role of stigma in the delivery of TB/HIV healthcare.     

Sexual risk behaviours and barriers to HIV testing among clients of female sex workers in Guatemala: a qualitative study

Few interventions have targeted clients of female sex workers in Central America, despite their potential role in HIV/STI prevention. Semi-structured interviews were conducted with 30 clients of female sex workers on attitudes towards prevention of HIV/STIs, barriers to condom use and behaviour towards HIV/STI testing and treatment in Escuintla, Guatemala. Despite high knowledge of condoms as an HIV/STI preventive measure, the decision to use them was often based on the client's social judgment of the woman's sexual conduct. Regular clients reported lower condom use. Clients' risk perception diminished with the awareness of the public HIV/STI clinic addressed to female sex workers. Most preferred private clinics to increase confidentiality and were reluctant to take the HIV test for fear of a positive result. Outreach programmes offering HIV/STI counselling and testing to clients of female sex workers could increase their test uptake and health-seeking behaviour and reduce potential transmission to the general population.     

HIV/AIDS case managers and client HIV status disclosure: perceived client needs, practices, and services

People living with HIV/AIDS often need assistance in deciding whether or how to disclose their HIV status to others, and case managers are in a unique position to offer this assistance. The current study surveyed 223 case managers providing services to people living with HIV/ AIDS in NewYork State. The survey was conducted anonymously, and case managers were sampled at the agency level. Results showed that two-thirds of case managers routinely discuss disclosure issues with their HIV-positive clients. However, case managers often felt that they lacked the resources to provide assistance with disclosure decisions, and 66 percent of those who routinely discuss disclosure issues had not received training in assisting with disclosure to sex and injection drug-sharing partners. HIV disclosure issues were also seen by case managers as only one of many pressing issues facing their HIV-positive clients; other pressing issues were housing, food, medical care, mental health treatment, and preventing HIV transmission. These results indicate a need for training and resources to facilitate HIV status disclosure assistance services offered by case managers.     

294名性服务人员的艾滋病知识、行为、HIV感染调查

[目的]了解性服务小姐的艾滋病知识、行为、HIV感染状况，更好地开展健康教育、行为干预。[方法]由专业人员制订调查方案并设计调查表，现场问巷同时采集5ml静脉血样。[结果]共查294人，她们对所调查的艾滋病传播途径、预防措施回答正确率均高于75．85％、非传播途径勾45．58％～84．35％、进行商业性行为时每次都使用安全套的人均少于51，30％。最近1次未用主要原因为感观认定客人无病（占33．33％）、客人增加报酬（占29．55％）。HIV抗体均为阴性。[结论]性服务人员大多数已掌握了预防艾滋病的理论知识，在行动中安全套使用率却很低。在开展健康教育、行为干预时，重点应及时纠正其进行商业性行为时错误观念，同时加强对男方艾滋病健康教育、来改变其高危行为。     

Uptake of HIV testing and HIV positivity among presumptive tuberculosis patients at Puducherry,South India

Setting:

Puducherry, a district in South India with a low prevalence of human immunodeficiency virus (HIV) infection (<1% among antenatal women).

Objectives:

1) To estimate the proportion of patients with known HIV status who were HIV-positive, 2) to describe the demographic and clinical characteristics of patients with unknown HIV status among presumptive TB patients, and 3) to assess the additional workload at HIV testing centres.

Design:

In this cross-sectional study, consecutive presumptive TB patients attending microscopy centres for diagnosis during March–May 2013 were asked if they knew their HIV status. Patients with unknown HIV status were offered voluntary counselling and HIV testing.

Results:

Of 1886 presumptive TB patients, HIV status was ascertained for 842 (44.6%); 28 (3.3%) were HIV-positive. The uptake of HIV testing was significantly higher in younger age groups, males, residents of Puducherry and smear-positive TB patients. The median increase in the number of clients tested for HIV per day per testing centre was 1 (range 0–6).

Conclusion:

The uptake of HIV testing was low. HIV prevalence was higher among presumptive TB patients than in antenatal women, and as high as in TB patients. With minimal increase in workload at HIV testing centres, HIV testing could be implemented using existing resources.     

HIV, AIDS and human services: exploring public attitudes in West Hollywood, California

The provision of human services associated with HIV and AIDS has been a controversial issue in Western countries, given the degree of stigma attached to AIDS, and the high level of public concern about the possibility of contracting HIV. Previous research on attitudes to controversial human services has identified some key characteristics associated with negative attitudes and resistant 'not-in-my-backyard' behaviour. Attitudes towards HIV- and AIDS-related services may be affected by other factors as well; in particular, they may be related to self-identified sexual orientation, given the role of HIV and AIDS in the emergence of a strong gay political identity. However, little research has yet been conducted to explore how knowledge and attitudes towards these services in particular localities are associated with a range of characteristics of local residents, including sensitive information such as sexual orientation and household HIV status, and how these might contribute to the creation of more accepting environments. This paper provides an analysis of a 1994 city-wide survey conducted in West Hollywood, California. This small city has a large and politically-organized gay and lesbian population, as well as significant numbers of residents in other, diverse social groupings, and has experienced high levels of HIV infection and AIDS relative to the surrounding Los Angeles County. Although issues of HIV and AIDS service provision have been well publicized in the city, residents may be expected to hold rather different sets of knowledge about and attitudes to these services, depending on their personal characteristics. Analysis of the survey data reveals that a large proportion of residents of West Hollywood rated HIV and AIDS services as very important, but there were interesting differences among groups. Most notably, variation in knowledge of services and attitudes to services (rating of importance) was particularly associated with age and language, but was less affected by sexual orientation and household HIV status.     

Responsibility and risk: accounts of reasons for seeking an HIV test

Using data from recordings of HIV test counselling sessions in publicly funded sites in Northern California, US, this paper examines the discussion of clients' reasons for testing as a site for self-presentation. While counsellors attempt to use the reason for testing discussion as a lead-in to a discussion of risk behaviour, clients often describe their testing as part of a routine, not in response to a specific risk. Clients use three practices to present themselves as reasonable and responsible people who are in control of their HIV status. First, clients present the normal and routine nature of testing, thereby portraying their reasonableness in seeking an HIV test. Secondly, clients deny or downgrade their risk when counsellors seek to identify a specific risk. Thirdly, when introducing a particular risk, clients package it within mitigating contexts that emphasise their knowledge about and control over the risk. These practices can make it difficult for counsellors to focus the counselling session on a specific risk incident. One of the counsellors in our dataset provides an alternative approach that manages to elicit risk and legitimates routine testing as a reason for testing.     

'What if they ask how I got it?' Dilemmas of disclosing parental HIV status and testing children for HIV in Uganda

BACKGROUND: Limited research has been conducted outside Western settings on how HIV-positive parents decide to test and disclose their own HIV status to children. We conducted a qualitative study in 2001 and 2005 to assess parent attitudes and current counselling policy and practice regarding child testing and parental disclosure in Uganda prior to the roll-out of antiretroviral therapy. METHODS: Parent perspectives were obtained through extended in-depth interviews with 10 HIV-positive parents recruited from The AIDS Support Organization (TASO), Entebbe branch. Counselling policy and practice were explored through key informant interviews with directors and two counsellors from each of five Ugandan counselling institutions with national or regional coverage. RESULTS: Respondents had 51 children ranging from 4 to 36 years with a median age of 13. Five of 10 parents had disclosed their status to their children, usually to all, and four of these had tested one child for HIV. All those who tested any child had also disclosed their status to some or all of their children. Parents regularly worried that their children may be infected, but all preferred to wait for emergence of symptoms before considering HIV tests, citing fear of children's emotional reaction and lack of perceived benefits from knowing status. Counselling policy directors confirmed the absence of policy and training guidelines on the subject of parent-child disclosure. Counsellors reported improvising and giving inconsistent advice on this common concern of clients. CONCLUSIONS: Concerns over disclosure to children of parent's HIV status and testing children for HIV represent a major psychological burden for HIV-positive parents. Further research is needed, but current counselling practice could be improved now by adapting lessons learned from existing research.     

Female Migrant Sex Workers in Moscow: Gender and Power Factors and HIV Risk

This study aimed to build formative knowledge regarding HIV risks in female migrant sex workers in Moscow, focusing on gender and power. This was a collaborative ethnographic study, informed by the theory of gender and power, in which researchers conducted minimally structured interviews with 24 female sex workers who were migrants to Moscow and who provided sexual services to male migrant laborers. Overall, the female migrant sex workers engaged in HIV risk behaviors and practiced inadequate HIV protection with their clients. These behaviors were shaped by gender and power factors in the realms of labor, behavior, and cathexis. In the labor realm, because some female migrants were unable to earn enough money to support their families, they were pushed or pulled into sex work providing service to male migrants. In the behavior realm, many female migrant sex workers were intimidated by their male clients, feared violence, and lacked access to women's health care and prevention. In the cathexis realm, many had a sense of shame, social isolation, emotional distress, and lacked basic HIV knowledge and prevention skills. To prevent HIV transmission requires addressing the gender and power factors that shape HIV/AIDS risks among female migrant sex workers through multilevel intervention strategies.     

Abuse,HIV status and health-related quality of life among a sample of HIV positive and HIV negative low income women

The assessment of a persons quality of life as it relates to health, HIV status and intimate partner violence (IPV) among women has been limited in its scope of investigation. Consequently, little is known about the adjusted and combined effects of IPV and HIV on womens health status and QOL. 445 women (188 HIV + 257 HIV –) residing in an urban low income area were interviewed regarding current IPV experiences (no IPV, IPV more than 1 year ago, IPV in last year), HIV status (positive and negative), use of illicit drugs, and presence of instrumental social support. Health-related QOL (HRQOL) was measured using the MOS-HIV. Stratified bivariate analyses demonstrate that living with HIV or having experienced IPV in the past year was significantly associated with poorer levels of HRQOL. Multiple logistic regression models indicate a robust negative relationship between the experience of IPV in the past year, living with HIV, use of illicit drugs and a protective effect of social support on womens reported HRQOL. The results of the bivariate and multivariate analyses provide evidence that there are independent and adjusted detrimental associations of the experience of IPV and living with HIV with womens HRQOL. As HRQOL is a good indicator of physical and mental health, these findings should alert health care and other service providers to their responsibility to screen and treat women experiencing intimate partner violence and living with HIV.     

Women Identified with HIV at Labor and Delivery: Testing, Disclosing and Linking to Care Challenges

Objective To determine if women with undocumented HIV status in late pregnancy or at labor and delivery who are rapidly tested and identified as HIV infected have high-risk behaviors and psychosocial obstacles hindering postpartum follow-up. Methods Consenting participants (women with undocumented HIV status and ≥24 weeks gestational age (GA) and imminent delivery or ≥34 weeks GA) in 6 cities were rapidly tested and interviewed. HIV-positive women were offered follow-up. Results From 2001–2005, 54 HIV-infected women were identified: median age 26 years; 91% African American; 11 (20%) lost custody of their infants; 30 (56%) knew they or their partner were HIV-infected, but had no antenatal HIV care; 25 met criteria for starting antiretroviral therapy. Comparison between 48 HIV-infected and 130 HIV-negative women, tested and interviewed at the same hospitals, showed HIV-infected women more likely to be African American (P < .01) and report no prenatal care (P < .001), use street drugs (P < .01), have unstable residency (P < .05), not live with the father of their infant (P < .001), and have children in foster care (P < .01). Sixteen women (30%) and 17 (31%) infants did not remain in follow-up study due to relocation, child protective custody, and psychosocial issues including frequent substance use. Conclusion Over half of HIV-infected women knew they or their partner were infected with HIV, but did not initially disclose their status. Increased support services and substance abuse treatment are critical to facilitate better continuity of care for these socially marginalized women. This research was supported by the National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention (CDC) under cooperative agreements U64/217724, 417719, 517715, 617734, 479935. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention. Precis: Women presenting to labor and delivery settings with undocumented HIV status have often experienced previous social marginalization, may not disclose their status, and need intensive social support during the post-partum period.     

人类免疫缺陷病毒感染者与其家属的社会健康状况及其影响因素

目的 调查湖南省某获得性免疫缺陷综合征(AIDS)比较集中的地区人类免疫缺陷病毒(HIV)感染者及其家属的社会健康状况,探讨社会健康状况与应对方式、社会支持之间的关系.方法 采用自测健康评定量表(SRHMS)中的社会健康评定了量表、社会支持评定量表(SSAS)以及特质应对方式问卷(TCSQ),对51例HIV感染者(感染组)、49名HIV感染者的家属(家属组)、96名普通村民(对照组)进行调查.结果 (1)在社会健康总分、消极应对得分及社会支持总分上,感染组、家属组与对照组(62.9±18.6,79.8±18.0,86.5±21.3;28.7±4.3,27.2±5.4,25.9±6.4;33.8±8.1,41.0±6.6,38.1±6.8)之间的差异都具有统计学意义(F=18.16、5.21、13.23,P值均<0.01);(2)支持利用度、是否为中高等文化、足否丧偶及主观支持对感染者的社会健康状况有显著的预测作用(R~2=0.73,F=27.78,P<0.01);(3)主观支持、消极应对方式对感染者家属的社会健康状况有显著的预测作用(R~2=0.32,F=12.35,P<0.01).结论 HIV感染者及其家属的应对方式较为消极,对支持的利用度较低,社会健康状况较差,有必要对他们实施心理干预.     

既往有偿献血HIV感染者/AIDS病人家庭的社会心理压力影响因素的通径分析

[目的]探讨既往有偿献血HIV/AIDS家庭的社会心理健康影响因素,分析各因素之间的相互作用。[方法]随机地访谈HIV感染者/AIDS病人家庭155户,通过调查问卷进行资料收集,并对影响HIV/AIDS家庭的心理压力的相关因素作路径分析。[结果]影响HIV/AIDS家庭的社会心理压力的主要因素依次是：是否有AIDS症状,社会歧视指数,劳动力下降指数,家庭人均收入减少指数,艾滋病的认知指数。是否有AIDS症状和社会歧视指数对社会心理压力的影响较大。[结论]延缓艾滋病人的疾病进展,政府和社会要加强艾滋病宣传教育,减少歧视,改善艾滋病人受到不公正对待的境遇,增强病人与艾滋病斗争的信心。     

Mobilizing collective identity to reduce HIV risk among sex workers in Sonagachi, India: the boundaries, consciousness, negotiation framework

The significantly low rate of HIV infection and high rate of condom use among sex workers in Kolkata, India is partially attributable to a community-led structural intervention called the Sonagachi Project which mobilizes sex workers to engage in HIV education, formation of community-based organizations and advocacy around sex work issues. This research examines how Sonagachi Project participants mobilize collective identity and the manner in which collective identity influences condom use. Using purposive sampling methods, 46 Sonagachi Project participants were selected in 2005 for in-depth qualitative interviews. Taylor and Whittier's (Taylor, V & Whittier, N (1992). Collective identities in social movement communities: lesbian feminist mobilization. In A. Morris & C. Mueller (Eds.) Frontiers in social movement theory. New Haven, CT: Yale University Press) model of identity-formation through boundaries, consciousness and negotiation was used to interpret results. Subjects mobilized collective identity by (1) building boundaries demarcating in-group sex workers from out-group members, (2) raising consciousness about sex work as legitimate labor and the transformative change that results from program participation, and (3) negotiating identity with out-group members. This research establishes a conceptual link between the boundaries, consciousness and negotiation framework of collective identity mobilization and condom use. Condom use among sex workers is motivated by each element of the boundaries, consciousness and negotiation model: condoms mark boundaries, enunciate the consciousness that sex with clients is legitimate labor, and help negotiate the identity of sex workers in interactions with clients.     

Developing consumer involvement in rural HIV primary care programmes

Objectives As part of a broader medical and psychosocial needs assessment in a rural region of northern California, USA, five focus groups were conducted to explore innovative approaches to creating a system of consumer involvement in the delivery of HIV primary care services in the region. Design A total of five focus groups (n = 30) were conducted with clients from three of five counties in the region with the highest number of HIV patients receiving primary care. Setting and participants Participants were recruited by their HIV case managers. They were adults living with HIV, who were receiving health care, and who resided in a rural mountain region of northern California. Variables studied Group discussions explored ideas for new strategies and examined traditional methods of consumer involvement, considering ways they could be adapted for a rural environment. Results Recommendations for consumer involvement included a multi‐method approach consisting of traditional written surveys, a formal advisory group, and monthly consumer led social support/informal input groups. Specific challenges discussed included winter weather conditions, transportation barriers, physical limitations, confidentiality concerns, and needs for social support and education. Conclusions A multiple‐method approach would ensure more comprehensive consumer involvement in the programme planning process. It is also evident that methods for incorporating consumer involvement must be adapted to the specific context and circumstances of a given programme.     

HIV related knowledge and prevention among Thai female commercial sex workers in Japan

A survey of 87 Thai female commercial sex workers (TCSW) was conducted in Tokyo and surrounding areas to investigate their: 1) living conditions, 2) knowledge about HIV/AIDS and sources of information, and 3) working conditions and dealings with clients. Data were mainly collected by “snowballing” with semi-structured interviews. The results showed a majority of participants knew HIV could be contracted through sexual intercourse and that condom use could protect against HIV infection. However, some TCSW reported failing to use condoms despite having requested clients to do so. Reasons for client compliance with condom use were discussed. Although a majority of the participants underwent HIV testing at least once every 3 months, they did not learn much about HIV prevention through public information and education. The results suggest that workers and clients need more detailed information concerning HIV prevention as well as a greater accessibility.     

HIV-infected women's experiences of pregnancy and motherhood in Cape Town,South Africa

Antenatal services provide a valuable opportunity for the uptake of prevention of mother-to-child transmission (PMTCT) of HIV interventions and antiretroviral treatment (ART) for maternal health. While knowledge of HIV status during pregnancy is beneficial to both mother and child, PMTCT programmes may focus more on prevention and the physical aspects of health than the psychosocial impact of HIV on pregnancy and motherhood. The objective of this study was to examine South African women's perceptions of HIV infection in pregnancy and how they related to motherhood in the context of HIV infection. In-depth interviews were conducted with 17 HIV-positive pregnant and 11 ≤ 6-month postpartum women to elicit perspectives on HIV-positive pregnancy and motherhood. For most women who tested in pregnancy, the primary rationale for testing stemmed from a concern for their children; and anxiety around the risk of vertical transmission was highly prevalent. Women did not perceive any superficial differences between themselves and non-infected pregnant women and they compared HIV to any other chronic condition. However, they voiced anxiety about being infected and were preoccupied with keeping their children safe, both in pregnancy and postpartum. They described a diminished sense of pride about motherhood and an additional burden of guilt associated with carrying a vulnerable child, which made pregnancy different for them in comparison to uninfected women. Feeding posed a particularly difficult issue because by choosing formula feeding, women were protecting their children, yet this seemed to diminish their status as a mother, while at the same time publicising messages about being infected with HIV. While women identified externally with the social value of motherhood, the burden of HIV infection was seen as a destabilising threat to their identity as mothers.     

Improving HIV prevention programs: the role of identity in shaping healthy sexual behavior of rural adolescents in South Africa

A large body of literature highlights the role of culture and identity in how individuals manage and maintain health. Disappointingly there was no statistically significant decline in HIV prevalence in the 15–24 years age group in South Africa since 2007, Millennium Development Goal 6 indicator. This warrants a new approach to youth HIV prevention, which considers identity and culture, in male-dominant environments. We used identity-based motivation theory, which predicts that possible identities have a crucial influence on health-promoting behavior, to argue that girls are not currently attaining their low risk possible identities because sociocultural factors influence their behavior and compromise their health and economic outcomes. This study employed a cross-sectional survey among 285 rural black South African adolescents (mean age 16.7 years; 48.8% boys) to determine the salient social identity and the associated possible identities. We then tested whether youth behave in accordance with their possible identities. The dependent variables are non-risky behavior, risky behavior, and confidence to discuss sex. The independent variables are age, previous sex experience, and poverty. The adolescents chose gender as the most prominent social identity. Girls chose a safer possible identity than boys did, and girls do not actualize their possible identities while boys do. For girls, no dependent variables were significant. These results show that sociocultural barriers prevent the girls from actualizing their non-risky possible identity. Future adolescent HIV prevention programs aimed at reducing HIV should promote rights and responsibilities and consider cultural norms and beliefs to create a more gender-equal society that embraces less risky sexual behavior, in line with the idealized identity of girls. This to convince both male and female adolescents of the benefits, risks, and social harms embedded in certain traditional practices in a high HIV-prevalent environment.     

Preparing social workers to address HIV/AIDS prevention and detection: implications for professional training and education

The social work profession remains an untapped resource within the community for addressing HIV/AIDS prevention and early detection. This study investigated social workers' knowledge and practices relating to HIV prevention education, risk assessment, and case finding. A six page questionnaire was mailed to a random sample of 600 licensed social workers and licensed clinical social workers in Illinois. The sample was drawn from a list provided by the state department of professional regulation, stratified by geographic location. The final response rate for the survey was 51.3% (N = 308). Social work knowledge concerning HIV and AIDS was significantly related to the variables of age, geographic location, and practice setting. Respondents scored lower on knowledge items pertaining to their ability to perform a comprehensive sexual and drug risk assessment and to appropriately advise clients on HIV antibody testing. Most of the social workers in the sample provided minimal to no HIV-related services in their clinical practice. HIV-related behaviors were also significantly related to the variables of age, geographic location, and practice setting. Multiple logistic regression was used to test whether prior HIV/AIDS training predicted the presence of HIV-related practice behaviors, controlling for potential confounding factors. Both prior HIV-related training and education and prior work experience with HIV-infected clients were statistically significant and independent predictors of current HIV-related practice behaviors reported by social workers.