Psychosocial Differences Between Whites and African Americans Living With HIV/AIDS in Rural Areas of 13 US States

CONTEXT: Acquired immunodeficiency syndrome (AIDS) prevalence rates are increasing rapidly in rural areas of the United States. As rural African Americans are increasingly affected by human immunodeficiency virus (HIV), it is important to identify psychosocial factors unique to this group so that AIDS mental health interventions can be culturally contextualized to meet their unique needs. PURPOSE: The current study characterized psychosocial functioning in 43 rural African Americans living with HIV/AIDS and compared their levels of functioning to those of 196 HIV-infected rural white persons. METHODS: All participants were recruited through AIDS service organizations in 13 US states. Surveys were completed as part of a preintervention phase of a randomized clinical trial evaluating 2 mental health interventions for HIV-infected rural persons. FINDINGS: Compared to their white counterparts, fewer African Americans had progressed to AIDS. African American participants also reported higher levels of coping self-efficacy, more support from family members, and marginally fewer depressive symptoms, and they engaged in more active coping. African Americans who had greater HIV disease severity also received less support from family members and experienced more loneliness. CONCLUSIONS: Study findings caution that rural African Americans and whites living with HIV disease should not be considered a homogeneous group.     

Improving resource allocation decisions for health and HIV programmes in South Africa: Bioethical,cost-effectiveness and health diplomacy considerations

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012–2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.     

Colonialism,Biko and AIDS: Reflections on the principle of beneficence in South African medical ethics

This paper examines the principle of beneficence in the light of moral and epistemological concerns that have crystallized in the South African context around clinical care. Three examples from the South African experience affecting the development of bioethics are examined: medical colonialism, the death in detention of Steve Biko, and the HIV/AIDS epidemic. Michael Gelfand's book [(1948). The sick African: a clinical study. Cape Town: Stewart Printing Company.] on African medical conditions captures the ambiguous nature of colonial medicine that linked genuine medical treatment with the civilizing mission. Biko's death was a key historical event that deeply implicated the medical profession under apartheid. The present HIV/AIDS epidemic presents the gravest social and political crisis for South African society. All three experiences influence the meaning and relevance of beneficence as a bioethics principle in the South African context. This paper argues for a South African bioethics informed by a critical humanism that takes account of the colonial past, and that does not model itself on an “original wound” or negation, but on positive care-giving practices.     

Recommendations From a Research Consultation to Address Intervention Strategies for HIV/AIDS Prevention Focused on African Americans

Despite substantial federal resources spent on HIV prevention, research, treatment, and care, as well as the availability and dissemination of evidence-based behavioral interventions, the disparate impact of HIV on African Americans continues.In October 2007, 3 federal agencies convened 20 HIV/AIDS prevention researchers and care providers for a research consultation to focus on new intervention strategies and current effective intervention strategies that should be more widely disseminated to address the HIV/AIDS epidemic among African Americans.The consultants focused on 2 areas: (1) potential directions for HIV prevention interventions, defined to include behavioral, community, testing, service delivery, structural, biomedical, and other interventions; and (2) improved research methods and agency procedures to better support prevention research focused on African American communities.IN THE UNITED STATES, African Americans are the racial group most affected by HIV/AIDS. Although comprising approximately 13% of the US population, at the end of 2007 African Americans accounted for 46% of the estimated 1.1 million cases of HIV or AIDS, including 60% of cases among women.^1,2 Of the adult and adolescent HIV/AIDS cases reported during 2007, 47% were among African Americans, and new HIV incidence estimates indicate that 45% of new HIV cases in 2006 were among African Americans.^2,3 For African American men, the leading cause of infection is men having sex with other men, and for women the leading transmission route is heterosexual sex.^1,2Meta-analyses show that behavioral interventions are efficacious in reducing HIV risk behaviors and rates of sexually transmitted infections among heterosexually active African Americans,⁴ African American women,⁵ and African American and Hispanic patients in sexually transmitted disease clinics.⁶ In December 2008, the Centers for Disease Control and Prevention (CDC) released the 2008 Compendium of Evidence-Based HIV Prevention Interventions,⁷ which identifies 57 individual and group-level evidence-based interventions, including many such interventions for African Americans. A number of these evidence-based interventions, as well as additional community-level interventions, have been packaged⁸ and disseminated⁹ to a variety of community-based organizations, health departments, and HIV clinics.Despite the substantial resources spent by federal agencies on HIV prevention, research, treatment, and care, as well as the availability and dissemination of evidence-based behavioral interventions, the disproportionate impact of HIV on the African American community continues. Issues may include inadequate scale (e.g., more resources are needed for broader dissemination of evidence-based interventions), implementation challenges, and the need for stronger or different types of interventions. On October 17 and 18, 2007, the CDC, the National Institutes of Health (NIH), and the Health Resources and Services Administration (HRSA) convened a collaborative research consultation in Atlanta, Georgia, to discuss novel intervention strategies (with a focus on new intervention strategies and current effective intervention strategies that should be more widely disseminated) to address the HIV/AIDS epidemic among African Americans. Twenty consultants attended; these were primarily HIV/AIDS prevention researchers and providers who had experience in conducting research on determinants of health disparities or in developing, implementing, and evaluating HIV/AIDS prevention interventions targeting African Americans.The discussion focused on 2 areas: (1) future directions for HIV prevention interventions for African Americans, defined to include behavioral, community-level, testing, service delivery, structural, biomedical, and other interventions; and (2) improved research methods and agency procedures to better support prevention research focused on African American communities. The consultants were divided into 3 groups that focused on 3 populations—adult heterosexuals, youths, and men who have sex with men and men who have sex with men and women. Cross-cutting issues such as substance abuse and incarceration were discussed in each group. All consultants then reconvened as a large group, and recommendations from each group were presented and discussed with an eye toward advising agencies on future HIV/AIDS prevention research initiatives targeting African Americans.We summarize the recommendations from the consultation. Many of the recommendations were common across the 3 subpopulations, so the recommendations are provided around the 2 main areas of focus—namely, directions for HIV prevention interventions and research methods and support needed for HIV prevention research with African American communities.     

Associations of poverty, substance use, and HIV transmission risk behaviors in three South African communities

The majority of the world's HIV infections occur in communities ravished by poverty. Although HIV/AIDS and poverty are inextricably linked, there are few studies of how poverty-related stressors contribute to HIV risk behavior practices. In this study, surveys were conducted in three South African communities that varied by race and socio-economic conditions: people living in an impoverished African township (N = 499); an economically impoverished but well infrastructured racially integrating township (N = 995); and urban non-impoverished neighborhoods (N = 678). Results showed that HIV/AIDS risks were closely related to experiences of poor education, unemployment, discrimination, violence, and crime. Although poverty-related stressors were associated with a history of alcohol and drug use, substance use did not moderate the association between poverty-related stressors and HIV risk behaviors. The findings suggest that HIV prevention strategies should not treat AIDS as a singled out social problem independent of other social ills.     

The Cultural and Community-Level Acceptance of Antiretroviral Therapy (ART) Among Traditional Healers in Eastern Cape,South Africa

The HIV/AIDS epidemic has profoundly impacted South Africa's healthcare system, greatly hampering its ability to scale-up the provision of antiretroviral therapy (ART). While one way to provide comprehensive care and prevention in sub-Saharan African countries has been through collaboration with traditional healers, long-term support specifically for ART has been low within this population. An exploratory, qualitative research project was conducted among 25 self-identified traditional healers between June and August of 2006 in the Lukhanji District of South Africa. By obtaining the opinions of traditional healers currently interested in biomedical approaches to HIV/AIDS care and prevention, this formative investigation identified a range of motivational factors that were believed to promote a deeper acceptance of and support for ART. These factors included cultural consistencies between traditional and biomedical medicine, education, as well as legal and financial incentives to collaborate. Through an incorporation of these factors into future HIV/AIDS treatment programs, South Africa and other sub-Saharan countries may dramatically strengthen their ability to provide ART in resource-poor settings.     

The last resort would be to go to the GP'. Understanding the perceptions and use of general practitioner services among people with HIV/AIDS

In England and Wales, departments of Genito-Urinary Medicine have led the clinical response to HIV infection and AIDS (HIV/AIDS). They provide an open-access self-referral service on a basis of strict confidentiality. People with HIV/AIDS have been found to be reluctant to involve their general practitioner (GP) in their care. Previous research has not investigated their decisions about service use in the context of their broader strategies for coping with the multiple psychological and social challenges, which are posed by HIV/AIDS as a chronic, stigmatised condition. We report a depth-interview study of twenty people with HIV/AIDS in a low-prevalence nonmetropolitan urban area of England. Their health care choices were products of complex judgements. Five concerns predominated: expertise, security, rights to care, confidentiality and the maintenance of normality. Transfer to GP care signified a transition from essential wellness to essential illness and represented a loss of biographical continuity. Their other concerns express problems of information management, which are universal features of stigmatising conditions. These may be heightened in the case of locally provided services, where any leakage of discrediting information is likely to impact directly on everyday life. These concerns should be understood and respected in policy initiatives to develop services.     

HIV counselling--a luxury or necessity?

WHO and UNAIDS have consistently promoted HIV counselling as a routine part of HIV testing in developing countries. Nevertheless, in many countries counselling is not considered a crucial accompaniment of testing services, and patients are tested without access to counselling during and after testing. Thus, information on the need for and results of counselling is needed to convince policy-makers and service managers to give greater priority to the development of counselling services. This qualitative study describes informational, social and emotional needs and problems of newly diagnosed seropositive patients attending public health services in Zimbabwe. Their basic factual information on HIV/AIDS was reasonable, but many patients equalled HIV to AIDS and conceptualized their infection as 'social and physical death'. This seriously impeded their capacity to use knowledge of their test results in a constructive way, and stimulated coping by denial and/or secrecy about their HIV status. These avoidant coping strategies discouraged clients from using condoms, seeking social support and taking measures to protect their vulnerable health. The complex and changing nature of clients' needs indicates that common short-cuts in counselling (e.g. giving brief information before and after the HIV test) are seriously flawed as a strategy to prepare clients for effective coping. Comprehensive pre- and post-test counselling are an essential preparation for coping effectively during and immediately after testing. Availability of supportive counselling beyond this first phase is essential to assist clients with needs and problems which will appear over time. Development of counselling interventions should be guided by research into their effectiveness and by national policy guidelines. Replacing fear-inducing HIV campaigns with interactive, constructive information about HIV prevention and care will increase the preparedness of the community as a whole for effective living with HIV.     

Mental health and psychosocial issues in HIV care

Human immunodeficiency virus (HIV) disease is associated with significant psychological stressors that require attention in their own right and can impact medical treatment. Psychological integration of illness occurs in identifiable stages and affects the patient's response to treatment interventions. Syndromes of depression, anxiety, stress, and substance abuse associated with HIV disease require recognition and appropriate treatment. The psychosocial context of treatment is also an important factor in HIV care, especially for special populations. Counseling and support groups are important tools in comprehensive HIV care and should be tailored to the needs of HIV/acquired immune deficiency syndrome (AIDS) patients. Mental health issues also exist for professionals working in HIV care.     

Experiences to cope with HIV among infected women

The study aimed to describe HIV-positive women's reports and experiences in coping with the infection. A qualitative study was carried out in the context of a specialized care service in Fortaleza-CE in 2007. Participants were 14 women diagnosed with HIV infection, who participated in tape recorded interviews. The analysis of interviews contents revealed the category Motivations for coping with HIV/AIDS and the subcategories religiosity, social and family support, presence of children and professional complicity as positive factors for coping with the infection. In conclusion, these women need professional and family care and support to remain stimulated in the care process.     

The social construction of sexually transmitted infections (STIs) in South African communities

Since the medical link between sexually transmitted infections (STIs) and HIV/AIDS was established, there has been an increased focus on the spread of STIs in South Africa. The aim of this study was to provide an in-depth picture of the dynamics involved in sexuality and the spread of STIs and HIV/AIDS. The authors present the findings of a focus group study, which was a part of a larger, national project addressing the broad question of health-care seeking behavior for STIs. A discourse analysis carried out on 10 focus groups reveals complex and rich narratives on the way in which STIs are constructed in South African communities. The dominant discourses focused on the continuing stigmatization of STIs, causal explanations, and prevention strategies. The analysis raises important recommendations for both educational interventions and health services toward the challenge of halting the spread of STIs and HIV/AIDS.     

Psychosocial problems and coping patterns of HIV seropositive wives of men with HIV/AIDS

The sociocultural milieu provides HIV positive women with fewer resources and more role responsibilities. The present research aimed at studying the psychosocial problems encountered in living, post HIV infection, and the coping patterns adopted by HIV seropositive wives of men with HIV/AIDS. In the background of an exploratory research design, thirty (n = 30) HIV positive women, attending Counseling Clinics in Bangalore (South India), selected through purposive sampling, were assessed using an interview schedule and a standardized coping scale. Majority of the respondents were the primary caregivers for their infected spouse and/or children. Content analysis of the problems revealed increased financial difficulties; problems in child care and support; compromised help-seeking due to stigma; problems in sexual interactions and communication in their marital relationship; role strain in caregiving; gender discriminatory and inadequate care; and increased concerns about parenting efficacy, post HIV infection. Escape avoidance was the most preferred coping strategy adopted by them. Situating the illness in a socio-familial context is indicated, and implications for social work and mental health practice follow from the findings.     

Psychosocial Problems and Coping Patterns of HIV Seropositive Wives of Men with HIV/AIDS

Abstract

The sociocultural milieu provides HIV positive women with fewer resources and more role responsibilities. The present research aimed at studying the psychosocial problems encountered in living, post HIV infection, and the coping patterns adopted by HIV seropositive wives of men with HIV/AIDS. In the background of an exploratory research design, thirty (n = 30) HIV positive women, attending Counseling Clinics in Bangalore (South India), selected through purposive sampling, were assessed using an interview schedule and a standardized coping scale. Majority of the respondents were the primary caregivers for their infected spouse and/or children. Content analysis of the problems revealed increased financial difficulties; problems in child care and support; compromised help-seeking due to stigma; problems in sexual interactions and communication in their marital relationship; role strain in caregiving; gender discriminatory and inadequate care; and increased concerns about parenting efficacy, post HIV infection. Escape avoidance was the most preferred coping strategy adopted by them. Situating the illness in a socio-familial context is indicated, and implications for social work and mental health practice follow from the findings.     

HIV / AIDS and STDs control: new policy perspectives

The prevention and control of HIV/AIDS is a social as well as a public health issue. This approach is reflected in new policy initiatives developed by the Government of India's National AIDS Control Organization in 1997. Future strategies will be based on a multisectoral, partnership-oriented approach. Bilateral agencies are encouraged to establish interventions in areas such as sexually transmitted disease (STD) control, condom distribution, counseling, health care, and hospice care. Special campaigns focused on youth and adolescents, including the inclusion of HIV/AIDS in the school curriculum, are planned. New strategies will be developed to address the HIV risk associated with drug abuse. The home- and community-based care of HIV/AIDS patients will be promoted, with emphasis on emotional and social support needs. Other areas to be addressed include the integration of STD control with primary health care, a blood transfusion policy, education for commercial sex workers, an end to discrimination against people with AIDS, and expansion of the national sentinel surveillance system.     

Domestic violence, sexual ownership, and HIV risk in women in the American deep south

Domestic violence and sexual abuse are important correlates of HIV risk in women. This paper examines the links between HIV risk and domestic violence in women in a region with the highest HIV/AIDS rates in the United States. The theoretical framework incorporates Butler's (1993) and (1990) concept of performative gender and Collins' (2000) "controlling images" of African American women as a context for domestic violence in the Deep South. Two focus groups were convened to develop a definition of domestic violence as HIV risk; 50 in-depth individual interviews of HIV-positive women were subsequently conducted for specific information on the topic. A final focus group was conducted for verification and feedback. The interview data revealed that controlling images of women as sexualized bodies were enacted through rape, sexual coercion, and name-calling in intimate relationships. The main finding was that the women lacked the ability to control sexual activities (including condom use) in abusive relationships with HIV-positive men. The women used various strategies to escape abusive partners and to obtain treatment for HIV/AIDS. The study concludes that the links between gender inequity, domestic violence, and HIV transmission should appear in prevention materials to encourage domestic violence screening in health settings, and to provide abused women with information on the not-so-obvious risks of being infected in abusive relationships.     

Men's involvement in the South African family: engendering change in the AIDS era

The literature on the South African family and its response to the HIV/AIDS epidemic is rife with accounts of men that reflect a deficit model of male involvement. Few acknowledge the historical, economic and social complexities of male involvement in family life. As the South African family undergoes demographic, social and economic transformation there is a need to describe the range of roles played by all household members, including men. This paper examines data collected over two and a half years from a small sample of households affected by HIV/AIDS in rural KwaZulu Natal, South Africa. Non-participant observations were made during outreach visits by research staff to twenty households caring for at least one adult with disease symptoms indicative of TB or AIDS. We find that men are positively involved with their families and households in a wide range of ways. They care for patients and children, financially support immediate and extended family members and are present at home, thereby enabling women to work or support other households. As the qualitative data demonstrate, however, such activities are often not acknowledged. The dominant perception of both female respondents and research assistants continues to be that men are not caring for their families because they are irresponsible and profligate. We consider reasons why this disjuncture exists and how more men might be encouraged to fulfil such roles and activities as their families and households suffer the social and economic impacts of HIV/AIDS.     

African American church-based HIV testing and linkage to care: assets,challenges and needs

The US National HIV AIDS strategy promotes the use of faith communities to lessen the burden of HIV in African American communities. One specific strategy presented is the use of these non-traditional venues for HIV testing and co-location of services. African American churches can be at the forefront of this endeavour through the provision of HIV testing and linkage to care. However, there are few interventions to promote the churches’ involvement in both HIV testing and linkage to care. We conducted 4 focus groups (n = 39 participants), 4 interviews and 116 surveys in a mixed-methods study to examine the feasibility of a church-based HIV testing and linkage to care intervention in Philadelphia, PA, USA. Our objectives were to examine: (1) available assets, (2) challenges and barriers and (3) needs associated with church-based HIV testing and linkage to care. Analyses revealed several factors of importance, including the role of the church as an access point for testing in low-income neighbourhoods, challenges in openly discussing the relationship between sexuality and HIV, and buy-in among church leadership. These findings can support intervention development and necessitate situating African American church-based HIV testing and linkage to care interventions within a multi-level framework.     

AIDS and the social side of health

The presence of AIDS in epidemic proportions in the African context can directly and indirectly affect the health of the majority of people. AIDS highlights the social side of health, those factors of a social nature that enhances or potentially weakens the health status of individuals and whole communities. Attention solely on a limited range of social behaviors or health activities may obscure this fact with the consequence that the spread of HIV/AIDS is not controlled. Focus is turned in this paper to the stress in AIDS policies and programs on terminal illness more than on terminal life. This approach, if not altered, can increase the vulnerability of persons who live with AIDS. The influence that the subordination of women exerts on the spread of HIV infection calls into question the traditions of male sexuality. The adverse effects of HIV on the health of men as well as women suggest the urgent need for re-assessment of the concepts of maleness held in the region. Change in male attitudes and behavior may require change in legislation and a resocialization to a new orientation in male/female relationship. The health of family members may be endangered because of the demands of the care-giving role. Traditional community mechanisms for coping with illnesses may be inadequate in the face of an epidemic. Rather than the pursuit of strategies to assist categories of selected persons, such as widows or orphans, whole affected communities will need to be approached as weakened families. It is questioned whether the health care system can adequately respond to the health requirements of the many when resources are drained, health care providers are overburdened, and primary health care is fragmented because of AIDS. The social dimension of health makes it imperative that policy and program measures to stop AIDS be a collective, balanced social and biomedical scientific effort.     

Position of The Canadian Dietetic Association and The American Dietetic Association: nutrition intervention in the care of persons with human immunodeficiency virus infection

The goals of nutrition intervention in HIV disease include early assessment and treatment of nutrient deficiencies, the maintenance and restoration of lean body mass, and support for activities of daily living and quality of life. The maintenance and restoration of nutritional stores is closely interrelated and interdependent with each of the other recommended medical therapies. Therefore, it is vital to the health of persons with HIV/AIDS to have access to the services of a registered dietitian, who is the essential member of the health care team for providing nutrition care (48). The registered dietitian should take an active role in developing nutrition care protocols for HIV/AIDS in their practice setting. The dietetic professional must take responsibility for obtaining and maintaining current knowledge in this area and take the lead in translating current nutrition knowledge and research into practical and realistic nutrition guidelines for the individual with HIV/AIDS. Further research is needed in the area of HIV/AIDS and nutrition. Registered dietitians and other members of the health care team are encouraged to conduct nutrition research in the area of nutrition interventions and outcomes of nutrition therapy. Additionally, government health related agencies, national AIDS-related organizations, and private industry should be encouraged to provide funding sources and support to the issue of research in nutrition related problems and interventions in HIV/AIDS.     

Psychosocial Differences Between Urban and Rural People Living With HIV/AIDS

Abstract: During the past decade, many investigations have examined the life circumstances of people living with HIV disease. Most of these studies, however, have focused on HIV-infected people in large metropolitan areas. This study compares the psychosocial profiles of rural and urban people living with HIV disease. Anonymous, self-administered surveys were completed by 276 people with HIV/AIDS in a Midwestern state. The assessment instrument measured respondents' quality of life, perceptions of loneliness, social support, experiences with AIDS-related discrimination, access to services, and illness-related coping strategies. Compared with their urban counterparts, rural people with HIV reported a significantly lower satisfaction with life, lower perceptions of social support from family members and friends, reduced access to medical and mental health care, elevated levels of loneliness, more community stigma, heightened personal fear that their HIV serostatus would be learned by others, and more maladaptive coping strategies. Programs that are designed to improve the life circumstances of people with HIV disease in rural areas—particularly those that facilitate access to adequate health care, increase perceptions of social support, and improve illness-related coping—are urgently needed.