HIV This Week

Sebert Kuhlmann AK, Kraft JM, Galavotti C, Creek TL, Mooki M, Ntumy R. Radio role models for the prevention of mother-to-child transmission of HIV and HIV testing among pregnant women in Botswana. Health Promot Int. 2008 Apr 11 [Epub ahead of print]

Although Botswana supports a program for the prevention of mother-to-child-transmission of HIV (PMTCT), many women initially did not take advantage of the program. Using data from a 2003 survey of 504 pregnant and post-partum women, Sebert Kuhlmann and his colleagues assessed associations between exposure to a long-running radio serial drama that encourages use of the PMTCT program and HIV testing during pregnancy. Controlling for demographic, pregnancy and other variables, women who spontaneously named a PMTCT character in the serial drama as their favourite character were nearly twice as likely to test for HIV during pregnancy as those who did not. Additionally, multiparity, knowing a pregnant woman taking AZT, having a partner who tested, higher education and PMTCT knowledge were associated with HIV testing during pregnancy. Identification with characters in the radio serial drama is associated with testing during pregnancy. Coupled with other supporting elements, serial dramas could contribute to HIV prevention, treatment and care initiatives.

Editors’ note: This programme went further than public service announcements and counselling sessions to raise awareness of PMTCT services. It used two fundamental principles: modelling (showing people how to change) and reinforcement (supporting their efforts to change and to maintain healthy behaviours). The radio drama was the modelling component and may have helped some women to see HIV testing in pregnancy as a good choice supported by social norms. It is interesting to speculate whether this programme paved the way for broad acceptance of the introduction of a routine offer of antenatal testing in 2004.

Wringe A, Isingo R, Urassa M, Maiseli G, Manyalla R, Changalucha J, Mngara J, Kalluvya S, Zaba B. Uptake of HIV voluntary counselling and testing services in rural Tanzania: implications for effective HIV prevention and equitable access to treatment. Trop Med Int Health. 2008;13(3):319-27.

Wringe and colleagues aimed to describe the associations between socio-demographic, behavioural and clinical characteristics and the use of HIV voluntary counselling and testing (VCT) services among residents in a rural ward in Tanzania. Eight thousand nine hundred and seventy participants from a community-based cohort were interviewed, provided blood for research HIV testing, and were offered VCT. Univariate and multivariate logistic regression was used to identify socio-demographic, clinical, and behavioural factors associated with VCT use. Although 31% (1246/3980) of men and 24% (1195/4990) of women expressed an interest in the service, only 12% of men and 7% of women subsequently completed VCT. Socio-demographic factors, such as marital status, area of residence, religion and ethnicity influenced VCT completion among males and females in different ways, while self-perceived risk of HIV, prior knowledge of VCT, and sex with a high-risk partner emerged as important predictors of VCT completion among both sexes. Among males only, those infected with HIV for 5 years or less tended to self-select for VCT compared to HIV-negatives (adjusted odds ratio = 1.43; 95% CI: 0.99-2.14). This contributed to a higher proportion of HIV-positive males knowing their status compared to HIV-positive females.  In this setting, a disproportionate number of HIV-positive women are failing to learn their status, which has implications for equitable access to onward referral for care and treatment services. Evidence that some high-risk behaviours may prompt VCT use is encouraging, although further interventions are required to improve knowledge about HIV risk and the benefits of VCT. Targeted interventions are also needed to promote VCT uptake among married women and rural residents.

Editors´note: Both the proportion of people interested in learning their HIV serostatus and the proportion of people who actually got tested are very low for a country with a sizeable HIV epidemic. It is likely that fear of stigma and discrimination had remained an important barrier to HIV testing during this study, since the Tanzanian government had already announced on radio and in newspapers that it intended to start providing free antiretroviral treatment though major hospitals.

Bastien S, Sango W, Mnyika KS, Masatu MC, Klepp KI. Changes in exposure to information, communication and knowledge about AIDS among school children in Northern Tanzania, 1992-2005. AIDS Care. 2008;20(3):382-7.

Bastien and colleagues investigate changes in primary school students’ reported exposure to AIDS information and communication, and knowledge levels from 1992 to 2005. A repeated cross-sectional design was used. In 1992, a self-administered questionnaire was completed by 2,026 sixth and seventh grade students from 18 randomly selected primary schools in Arusha and Kilimanjaro regions, Tanzania.  The same procedures were repeated in 2005 with a sample of 2,069 students. Mean values with 95% confidence intervals are reported. Chi-square was used to test for differences in proportions. Students in 2005 reported higher levels of exposure to information and communication from all sources than in 1992.  Knowledge scores also increased, yet there was a significant decline in four variables, two of which are related to transmission and two of which are factual.  An alarming decline in awareness of the condom as a preventative measure was found. Findings also indicate that myths related to transmission and infection persist. Salient sex differences remain, but the knowledge gap is narrowing.  Interventions should aim to stimulate discussion in young people’s social networks in order to increase overall exposure to AIDS information, communication and knowledge.

Editors´note: This large study of primary school students, drawn from the same location as a similar study conducted 13 years before, showed little improvement. Its findings underscore the continuing importance of sustained efforts to improve young people’s communication skills and provide them with opportunities to discuss HIV-related issues, challenge misconceptions, and address recurring myths. Examples include negative public discourse about condom efficacy and use and persistent myths about HIV acquisition via mosquito bites.

Hargreaves JR, Bonell CP, Boler T, Boccia D, Birdthistle I, Fletcher A, Pronyk PM, Glynn JR. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS. 2008; 30; 22(3):403-14.

Hargreaves and colleagues amied to assess the evidence that the association between educational attainment and risk of HIV infection is changing over time in sub-Saharan Africa. The authors conducted a systematic review of published peer-reviewed articles. Articles were identified that reported original data comparing individually measured educational attainment and HIV status among at least 300 individuals representative of the general population of countries or regions of sub-Saharan Africa. Statistical analyses were required to adjust for potential confounders but not over-adjust for variables on the causal pathway. Approximately 4000 abstracts and 1200 full papers were reviewed. Thirty-six articles were included in the study, containing data on 72 discrete populations from 11 countries between 1987 and 2003, representing over 200,000 individuals. Studies on data collected prior to 1996 generally found either no association or the highest risk of HIV infection among the most educated. Studies conducted from 1996 onwards were more likely to find a lower risk of HIV infection among the most educated. Where data over time were available, HIV prevalence fell more consistently among highly educated groups than among less educated groups, in whom HIV prevalence sometimes rose while overall population prevalence was falling. In several populations, associations suggesting greater HIV risk in the more educated at earlier time points were replaced by weaker associations later. HIV infections appear to be shifting towards higher prevalence among the least educated in sub-Saharan Africa, reversing previous patterns. Policy responses that ensure HIV-prevention measures reach all strata of society and increase education levels are urgently needed.

Editors’ note: Although data were available from only 11 countries, the findings are supported by evidence of behaviour change as well as theoretical plausibility. The ‘diffusion of innovations’ model would predict information seeking and adoption of new practices, such as condom use, by more-educated, more-empowered members of a population. This strongly suggests that larger reductions in HIV incidence can be achieved by improving school enrolment, such as through abolition of primary school fees (as has been done in Kenya, Malawi, Tanzania, and Uganda), and tailoring HIV prevention programmes for socially vulnerable groups, while creating positive social environments which reinforce safer HIV prevention behavioural norms across the population.

Lau JT, Choi KC, Tsui HY, Su X. Associations between stigmatization toward HIV-related vulnerable groups and similar attitudes toward people living with HIV/AIDS: Branches of the same tree? AIDS Care. 2007; 19(10):1230-40.

This study tested the hypothesis that stigmatization toward people living with HIV (PLHIV) was associated with stigmatization toward different vulnerable groups, including men who have sex with men, injecting drug users, female sex workers, and their clients. A number of scales and indicators were constructed for the purpose: the four Overall Stigmatization Scale for a Vulnerable Group (OSSVG) and the five Dimensional Stigmatization Scale (DSS) each measuring different dimensions of stigmatization toward the four vulnerable groups, together with four indicators measuring stigmatization toward PLHIV. A random sample of 2,008 Hong Kong Chinese adults aged 18-50 years in the general population were interviewed by telephone. Of these respondents, 22.8-76.8% perceived that female sex workers, clients of female sex workers, men who have sex with men and injecting drug users were pathological and 42-82.2% perceived them as immoral; 74.7% believed that PLHIV are promiscuous. Furthermore, the four OSSVG and the five DSS scales were inter-correlated with one another (Spearman coefficient = 0.11-0.67) and most of them were significantly associated with the four PLHIV stigmatization indicators (Odds Ratio = 1.25-4.27). Other factors were associated with the OSSVG and DSS scores (e.g. age, marital status, religion affiliation, education level, income and perceived severity of the HIV problem in Hong Kong). Campaigns for removing stigmatization toward these vulnerable groups are required in order to reduce stigmatization toward PLHIV. Stigmatization toward female sex workers and their clients might have been over-looked. The removal of the public’s blame on these groups for spreading HIV may be useful. The impact of HIV prevalence of a vulnerable group onto the associations between stigmatization toward that particular group and PLWHA warrants investigation.

Editors’ note: Layered stigmatisation or discrimination, attributed both to features of HIV and to non-HIV components such as how one contracted HIV infection, has not been well studied. Stigma is discrediting, reduces status in society, and is disempowering. This study did not examine discriminatory behaviours, but rather discriminatory attitudes or stigmatization, which can nonetheless be very harmful in Hong Kong society, as elsewhere. Effective community mobilisation and social change communication is required to address layered stigmatization.

King R, Katuntu D, Lifshay J, Packel L, Batamwita R, Nakayiwa S, Abang B, Babirye F, Lindkvist P, Johansson E, Mermin J, Bunnell R. Processes and Outcomes of HIV Serostatus Disclosure to Sexual Partners among People Living with HIV in Uganda. AIDS Behav. 2008;12(2):232-43. Epub 2007 Sep 8.

Disclosure of HIV serostatus to sexual partners supports risk reduction and facilitates access to prevention and care services for people living with HIV. To assess health and social predictors of disclosure as well as to explore and describe the process, experiences and outcomes related to disclosure of men and women living with HIV in Eastern Uganda, King and colleagues conducted a study among clients of The AIDS Support Organization (TASO) in Jinja, Uganda. The authors enrolled TASO clients in a cross-sectional study on transmission risk behaviour. Demographic and behavioural data and CD4 cell count measurements were collected. Among 1,092 participants, 42% were currently sexually active and 69% had disclosed their HIV serostatus to their most recent sexual partner. Multivariate logistic regression analysis showed that disclosure of HIV-status was associated with being married, having attended TASO for more than 2 years, increased condom use, and knowledge of partner’s serostatus. From these clients, 45 men and women were purposefully selected and interviewed in-depth on disclosure issues. Positive outcomes included risk reduction behaviour, partner testing, increased care-seeking behaviour, anxiety relief, increased sexual communication, and motivation to plan for the future.

Editors’ note: Almost half of the participants disclosed indirectly, a culturally appropriate method of conveying personal information in this setting but one that requires more human resources. Given the strong association found between knowledge of serostatus and disclosure, widespread promotion of couples counselling, with the option of mutual disclosure, can link couples to family-focused HIV treatment, care, and prevention opportunities. Both Uganda and Kenya are expanding home-based testing programmes that do exactly that.

Menon and colleagues aimed to examine emotional and behavioural difficulties in Zambian adolescents living with HIV, and to determine the relationship between disclosure of HIV status and mental health. In a cross-sectional survey, 127 adolescents living with HIV aged 11 to 15 years were recruited through clinics in the Lusaka region. Mental health was assessed using the youth report version of the Strengths and Difficulties Questionnaire (SDQ). Caregivers completed the parent SDQ. Sixty-two participants were invited for a semi-structured interview which probed views on attending a peer support group. Compared to a British community sample, participants had increased mental health problems (OR, 2.1), particularly emotional symptoms (OR = 3.6), and peer problems (OR = 7.1). The majority of the study subjects (n = 94) were receiving antiretroviral treatment, but only 48 (37.8%) had their HIV status disclosed to them. Those who had not had their HIV status disclosed to them were younger (P < 0.001) and less likely to be receiving antiretroviral treatment (P < 0.001). Controlling for these factors they were also more likely to score in the abnormal range of the emotional difficulties subscale (OR = 2.63, 95% CI: 1.11 to 6.26). Of 38 interviews transcribed, content analysis showed that only 3 individuals were opposed to participation in a peer-group programme, with the majority (23/38 ) expressing reasoned and positive responses, regardless of disclosure status. In conclusion, high rates of emotional and peer problems were found in this sample but disclosure of HIV status did not have a negative effect on mental health. Interventions to promote disclosure could facilitate access to emotional and peer support.

Editors’ note: Children with HIV are at increased risk of mental health problems but not necessarily as a result of their health status. In this study, Zambian young people aged 11 to 15 years aware of their serostatus were 2.5 times less likely to score in the abnormal range for emotional difficulty, after controlling for age, sex, and medication, than those who did not know. Since this is a cross-sectional study, it is difficult to know whether more psychologically stable children are more likely to learn their serostatus and even, whether families who choose to disclose have higher expressivity levels or tend to have more psychologically stable children. What is clear is that knowledge of serostatus is the door to participation in a peer support group that can provide psychological support.

Dlamini PS, Kohi TW, Uys LR, Phetlhu RD, Chirwa ML, Naidoo JR, Holzemer WL, Greeff M, Makoae LN. Verbal and physical abuse and neglect as manifestations of HIV/AIDS stigma in five African countries. Public Health Nurs 2007;24:389-99.

Dlamini and colleagues aimed to explore the experience of HIV-related stigma for people living with HIV in Lesotho, Malawi, South Africa, Swaziland, and Tanzania. The authors conducted a descriptive study using 43 focus groups (n=251 participants), which included male and female people living with HIV from both rural and urban areas and nurses working with people living with HIV. Participants were asked to relate incidents of HIV-related stigma that they had experienced or observed. Focus group discussions were taped, and data were content analyzed to identify examples of abuse (verbal and physical abuse and neglect) related to HIV stigma. Data analysis also explored targets of abuse, abusers, and consequences of abuse. Participant reports documented extensive verbal and physical abuse and neglect or negating ( disallowing of access to services and opportunities) experienced by people living with HIV and observed by nurses caring for them, and identified negative consequences experienced by people living with HIV whose HIV-positive status was disclosed to family, friends, or community members. The authors conclude that health care workers who encourage people living with HIV to disclose their HIV status must carefully consider the implications of encouraging disclosure in an environment with high levels of stigma, and must recognize the real possibility that persons living with HIV may experience serious verbal and physical abuse as a consequence of disclosure.

Editors’ note: In this five-country study, verbal abuse was common but physical abuse less so. The authors anticipate that, in contrast to the high HIV prevalence communities in which this study was conducted where many individuals, families, and health workers have already been confronted with their own feelings about HIV, there would be a higher incidence of abuse in communities where AIDS is less common. Neglect, including by health care workers, was also reported. Governments need to firmly address the problem of abuse, by explicit polices backed up by a system for monitoring their implementation and effects.

HIV continues to constitute a serious threat to the social and physical wellbeing of African mothers and their babies. In the hardest hit countries of sub-Saharan Africa, more than 60% of all new HIV infections are occurring in women, infants and young children. Mother-to-child transmission constitutes 90% of new HIV infections among infants and young children. Most of these infections can be prevented. However, the social stigma of HIV insidiously continues to undermine the success of prevention programmes. Ironically, some attributes or characteristics of prevention of mother-to-child transmission (PMTCT) programmes may in fact serve as catalysts to the stigmatization process. This paper identifies and discusses six potential initiators: (1) Routine HIV testing, (2) Six months exclusive breastfeeding, (3) Incentives, (4) Home visits, (5) Location of PMTCT program, and (6) PMTCT terminology. In all these areas, there are practical strategies that may be applied to reduce the chances of being stigmatized. These strategies are introduced and discussed.

Editors’ note: This paper describes a Malawian PMTCT programme that unintentionally discloses its clients’ HIV-positive status, thus compromising its ability to protect their right to privacy and confidentiality and contributing to their stigmatization. Lack of attention to the sociocultural and political tapestry in which women live will lead to similar negative results as PMTCT programmes are scaled up. This paper makes several suggestions on practical ways to better protect confidentiality and increase community acceptance, all of which could lead to increased programme uptake.

Morrow M, Arunkumar M, Pearce E, Dawson HE. Fostering disability-inclusive HIV/AIDS programs in northeast India: a participatory study. BMC Public Health 2007;267:125.

Manipur and Nagaland in northeast India are among the Indian states with the highest prevalence of HIV. Most prevention and care programs focus on identified “high risk” groups, but recent data suggest the epidemic is increasing among the general population, primarily through heterosexual sex. People with disability (PWD) in India are more likely than the general population to be illiterate, unemployed, and impoverished, but little is known of their HIV risk. This project aimed to enable HIV programs in Manipur and Nagaland to be more disability-inclusive. The objectives were to: explore HIV risk and risk perception in relation to PWD among HIV and disability programmers, and PWD themselves; identify HIV-related education and service needs and preferences of PWD; and utilise findings and stakeholder consultation to draft practical guidelines for inclusion of disability into HIV programming. Data were collected through a survey and several qualitative tools. The findings revealed that participants believe PWD in these states are potentially vulnerable to HIV transmission due to social exclusion and poverty, lack of knowledge, gender norms, and obstacles to accessing HIV programs. Neither HIV nor disability organisations currently address the risks, needs, and preferences of PWD. The Guidelines produced in the project and disseminated to stakeholders emphasise opportunities for taking action with minimal cost and resources, such as using the networks and expertise of both HIV and disability sectors, producing HIV material in a variety of formats, and promoting accessibility to mainstream HIV education and services. The human rights obligations and public health benefits of modifying national and state policies and programs to assist this highly disadvantaged population are also highlighted.

Editors’ note: This work highlights an important, underrepresented population with an increased risk of contracting HIV. People with disabilities often experience humiliation and social stigma. They may be vulnerable to exploitation, sexual abuse, and assumptions that they are not sexually active, along with decreased access to HIV prevention and care. HIV programmes and disability services providers need to work with disabled people to enable rapid and effective responses to the HIV-related needs of people with visual, hearing, physical, and intellectual impairments.

Lesch A, Swartz L, Kagee A, Moodley K, Kafaar Z, Myer L, Cotton M. Paediatric HIV/AIDS disclosure: towards a developmental and process-oriented approach. AIDS Care 2007;19:811-6.

As antiretroviral therapy becomes more widely available in low-resource settings and children with HIV live for longer periods, disclosure of HIV diagnosis to infected children is becoming increasingly important. This article reviews the current literature on HIV-related disclosure in light of theories of cognitive development, and argues for the adoption of a process-oriented approach to discussing HIV with infected children. Disclosure presents unique challenges to healthcare workers and caregivers of children with HIV that include controlling the flow of information about the child’s HIV status to him/her and deciding on what is in his/her best interest. Health care workers’ and caregivers’ views regarding disclosure to children may often be contradictory, with healthcare workers likely to support disclosing the diagnosis of HIV to children and caregivers more reluctant to discuss the disease with them. There is a clear need for practical interventions to support paediatric HIV disclosure which provide children with age-appropriate information about the disease.

Editors’ note: Decisions about when and how to disclose HIV status to a child need to consider the evolving capacity of children to understand about HIV infection and their socio-psychological readiness for learning their status. Understandably, caregivers may want to delay disclosure even when a child could take the information on board. Discussions between caregivers and healthcare workers are important to coming to agreement on tailoring the timing, manner, and content of disclosure to the child’s situation. The goals are mutual: supporting the child’s positive adaptation to the news and his or her engagement to stay healthy.

Klitzman R, Exner T, Correale J, Kirshenbaum SB, Remien R, Ehrhardt AA, Lightfoot M, Catz SL, Weinhardt LS, Johnson MO, Morin SF, Rotheram-Borus MJ, Kelly JA, Charlebois E. It’s not just what you say: relationships of HIV disclosure and risk reduction among MSM in the post-HAART era. AIDS Care 2007;19:749-56.

In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviours and partner variables. Klitzman et al interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviours. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had >1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for <5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study – the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART - indicates that almost one fifth reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.

Editors’ note: Disclosure is difficult for many people, not the least those who have learned their status more recently and who only have casual partners. This study of men who have sex with men reveals that being on treatment and viral load are not influencing decisions to disclose or not whereas other factors such as relationship type clearly are. Lack of disclosure combined with unprotected anal sex fuel ongoing transmission among men who have sex with men. Qualitative action oriented research to help people create solutions that work for them is needed.

Geibel S, van der Elst EM, King’ola N, Luchters S, Davies A, Getambu EM, Peshu N,Graham SM, McClelland RS, Sanders EJ.’Are you on the market?’: a capture-recapture enumeration of men who sell sex to men in and around Mombasa, Kenya. Population Council, Nairobi, Kenya. AIDS. 2007 Jun 19;21(10):1349-54.

Men who have sex with men (MSM) are highly vulnerable to HIV infection, but this population can be particularly difficult to reach in sub-Saharan Africa. We aimed to estimate the number of MSM who sell sex in and around Mombasa, Kenya, in order to plan HIV prevention research. The authors identified 77 potential MSM contact locations, including public streets and parks, brothels, bars and nightclubs, in and around Mombasa and trained 37 MSM peer leader enumerators to extend a recruitment leaflet to MSM who were identified as ‘on the market’, that is, a man who admitted to selling sex to men. They captured men on two consecutive Saturdays, 1 week apart. A record was kept of when, where and by whom the invitation was extended and received, and of refusals. The total estimate of MSM who sell sex was derived from capture-recapture calculation. As a result, capture 1 included 284 men (following removal of 15 duplicates); 89 men refused to participate. Capture 2 included 484 men (following removal of 35 duplicates); 75 men refused to participate. Of the 484 men in capture 2, 186 were recaptures from capture 1, resulting in a total estimate of 739 (95% confidence interval, 690-798) MSM who sell sex in and around Mombasa. Of these, 484 were contacted through trained peer enumerators in a single day. MSM who sell sex in and around Mombasa represent a sizeable population who urgently need to be targeted by HIV prevention strategies.

Editors’ note: Capture-recapture techniques were initially developed to ascertain the size of fish populations but they work well for people too! They can be used to establish the size of the population to be reached by programmes permitting assessment of service coverage against this denominator.

HIV risk and infection are markedly increased among sexual minority women injectors compared to other injecting drug users. Our ethnographic exploration of this well-documented but poorly understood phenomenon included 270 interviews and over 350 field observations with 65 sexual minority women injectors in New York City and Boston. We discuss findings in relation to four preliminary hypotheses. Neither the presence of gay or bisexual men in risk networks, nor a sense of invulnerability due to lesbian(or other sexual minority) identity seem to be plausible explanations of increased HIV among sexual minority women injectors. However, multiple marginalization was found to be pervasive and to have severe consequences that can be traced to increased HIV risk for many women in the study.

Editors’ note: Prevention programmes for women who have sex with women are virtually non-existent, in part because sexual risk is low, but, as this ethnographic study shows, risk from injecting practices can be compounded by marginalization. Engaging and empowering sexual minority women injectors for HIV prevention is not possible without bridging strategies that address multiple underlying concerns.

Meundi AD, Amma A, Rao A, Shetty S, Shetty AK. Cross-sectional population-based study of knowledge, attitudes, and practices regarding HIV/AIDS in Dakshina Kannada District of Karnataka, India. Int Assoc Physicians AIDS Care (Chic Ill) 2007 Jun 6; [Epub ahead of print].

The objective of this study was to assess AIDS-related knowledge, attitudes, and practices among the general population in South India. The 1669 participants (834 males, 835 females) aged 19-49 years were surveyed using a stratified 2-stage random sampling design with probability proportional to size. Although 54% of participants knew that AIDS is caused by “HIV” virus and 44% could correctly identify all modes of transmission, 52% believed in one or more myths, 41% did not know that condoms can prevent HIV, and 18% had not heard of a condom. Higher HIV knowledge scores were significantly associated with male gender, higher education, currently married, higher frequency of reading newspapers, listening to radio or watching television, and willingness to get tested for HIV (P <.01). Thirty-four percent felt that HIV-infected individuals should be kept away from others, and 40% were not willing to accept a family member with HIV. There was a significant and positive correlation between knowledge and attitude scores (P <.01). Among respondents who ever had sexual intercourse, significantly more males declared having more than one sexual partner compared to females (P <.01). Only 16% of respondents reported that they consistently used condoms. Sixty-two percent of the respondents were willing to undergo an HIV test if provided free of cost. This willingness to opt for HIV testing increased significantly with better knowledge score, better attitude score, and higher education status (P <.01). HIV prevention campaigns in India should focus on public education, stigma reduction, promotion of condom use, and risk-reduction behaviours in urban and rural communities targeted toward young adults.

Editors’ note: High levels of stigma, the cost of HIV testing, and low levels of knowledge combine to dissuade people from learning their HIV status in this district in Karnataka. A striking 41% of respondents did not know that condoms can prevent HIV infection and 40% were not willing to accept a family member living with HIV. Although India has made progress in increasing AIDS awareness, clearly much remains to be done.

Janni J. Kinsler, Mitchell D. Wong, Jennifer N. Sayles, Cynthia Davis, William E. Cunningham. The Effect of Perceived Stigma from a Health Care Provider on Access to Care Among a Low-Income HIV-Positive Population. AIDS Patient Care and STDs 2007, 21(8): 584-592.

Perceived stigma in clinical settings may discourage HIV-infected individuals from accessing needed health care services. Having good access to care is imperative for maintaining the health, well being, and quality of life of persons living with HIV. The purpose of this prospective study, which took place from January 2004 through June 2006, was to evaluate the relationship between perceived stigma from a health care provider and access to care among 223 low income, HIV-infected individuals in Los Angeles County. Approximately one fourth of the sample reported perceived stigma from a health care provider at baseline, and about one fifth reported provider stigma at follow up. We also found that access to care among this population was low, as more than half of the respondents reported difficulty accessing care at baseline and follow up. Perceived stigma was found to be associated with low access to care both at baseline (odds ratio [OR] = 3.29; 95% confidence interval [CI] = 1.55, 7.01) and 6-month follow up (2.85; 95% CI = 1.06, 7.65), even after controlling for sociodemographic characteristics and most recent CD4 count. These findings are of particular importance because lack of access or delayed access to care may result in clinical presentation at more advanced stages of HIV disease. Interventions are needed to reduce perceived stigma in the health care setting. Educational programs and modelling of nonstigmatizing behaviour can teach health care providers to provide unbiased care.

Editors’ note: Training and continuing education programmes for doctors, nurses, orderlies, assistants and other health care providers should address stigma – exploring provider attitudes and identifying behaviours which can convey stigma inadvertently. Patients themselves may feel vulnerable to disapproval and readily perceive stigma. Health care providers need to learn ways to express acceptance and set patients at ease so that they will freely access services.

Melendez RM, Pinto R. ‘It’s really a hard life’: Love, gender and HIV risk among male-to-female transgender persons. Cult Health Sex 2007;9:233-45.

Scientific studies demonstrate high rates of HIV infection among male-to-female transgender individuals and that stigma and discrimination place them at increased risk for infection. However, there is little research examining how gender roles contribute to HIV risk. This paper reports on in-depth interviews with 20 male-to-female transgender individuals attending a community clinic. Data reveal that stigma and discrimination create a heightened need for them to feel safe and loved by a male companion and that in turn places them at a higher risk for acquiring HIV. Male-to-female transgender individuals appear to turn to men to feel loved and affirmed as women; their main HIV risk stems from their willingness to engage with sexual partners who provide a sense of love and acceptance but who also may also request unsafe sexual behaviours. A model illustrating how HIV risk is generated from stigma and discrimination is presented.

Editors’ note: Male-to-female transgender individuals may experience considerable stigma and discrimination which may make them more likely to accept risky sexual behaviour in exchange for protection from a male partner - not unlike many women who lack the power to negotiate safe sex practices.

Chan KY, Stoove MA, Sringernyuang L, Reidpath DD. Stigmatization of AIDS patients: disentangling Thai nursing students’ attitudes towards HIV/AIDS, drug use, and commercial sex. AIDS Behav 2007 Mar 16; [Epub ahead of print]

This paper analyzes the interrelationships between HIV stigma and the co-stigmas of commercial sex (CS) and injecting drug use (IDU). Students of a Bangkok nursing college (N = 144) were presented with vignettes describing a person varying in the disease diagnoses (AIDS, leukaemia, no disease) and co-characteristics (IDU, CS, blood transfusion, no co-characteristic). For each vignette, participants completed a social distance measure assessing their attitudes towards the hypothetical person portrayed. Multivariate analyses showed strong interactions between the stigmas of AIDS and IDU but not between AIDS and CS. Although AIDS was shown to be stigmatizing in and of itself, it was significantly less stigmatizing than IDU. The findings highlight the need to consider the non-disease-related stigmas associated with HIV as well as the actual stigma of HIV in treatment and care settings. Methodological strengths and limitations were evaluated and implications for future research discussed.

Editors’ note: These attitudes likely reflect those of the society in which these nursing students live, which in the past has enacted repressive measures against people who use drugs while generally tolerating people who sell sex. The results of studies like this can help health professionals better understand the attitude shifts and behaviour changes they need to make to better serve their patients.

Taylor MM, Rotblatt H, Brooks JT, Montoya J, Aynalem G, Smith L, Kenney K, Laubacher L, Bustamante T, Kim-Farley R, Fielding J, Bernard B, Daar E, Kerndt PR. Epidemiologic investigation of a cluster of workplace HIV infections in the adult film industry: Los Angeles, California, 2004. Clin Infect Dis 2007;44:301-5.

Adult film production is a legal, multibillion dollar industry in California. In response to reports of HIV transmission by an adult film worker, Taylor and colleagues sought to determine the extent of HIV infection among exposed workers and to identify means of improving worker safety. The Los Angeles County Department of Health Services initiated an outbreak investigation that included interviews of infected workers to elicit information about recent sex partners, review of the testing agency’s medical records and laboratory results, molecular analysis of HIV isolates from the 4 infected workers, and a risk assessment of HIV transmission in the adult film industry. Many adult film workers participate in a monthly program of screening for HIV infection by means of polymerase chain reaction-based technology to detect HIV DNA in blood. A male performer tested negative for HIV on 12 February 2004 and 17 March 2004, then tested positive for HIV on 9 April 2004. During the period between the negative test results, he experienced a flulike illness after performing unprotected vaginal and anal intercourse for an adult film produced outside the United States by a US company. After returning to California, he performed unprotected sex acts for adult films with 13 female partners who had all tested negative for HIV in the preceding 30 days; 3 subsequently tested positive for HIV (a 23% attack rate). Contact tracing identified no reasonable sources of infection other than the male index patient. The authors conclude that although current testing methods may shorten the window period to diagnosis of new HIV infection, they fail to prevent occupational acquisition of HIV in this setting. A California Occupational Safety and Health Administration-approved written health and safety programme that emphasizes primary prevention is needed for this industry.  

Editors’ note: Given these findings, why can’t this legal, multibillion dollar industry move away from sole reliance on regular HIV testing and introduce safer sex techniques in all their movies – what a message that would send!

Johnny L, Mitchell C. “Live and let live”: An analysis of HIV/AIDS-related stigma and discrimination in international campaign posters. J Health Commun 2006;11:755-67.

As a corollary to The Declaration of Commitment adopted by the United Nations General Assembly Special Session on HIV/AIDS in June 2001, UNAIDS developed a World AIDS Campaign that sought to eradicate HIV-related stigma and discrimination. The campaign incorporated several educational strategies, including a poster campaign that advocated the just and equal treatment of people living with HIV. In an effort to develop an understanding of these educational efforts, Johnny and Mitchell deconstruct the 2002-2003 World AIDS Campaign posters. While the overall results suggest that the campaign has been successful in redefining images of HIV and AIDS, they also show that certain aspects of these posters may actually serve to reinforce stigma and discrimination. Using a visual studies approach to textual analysis, the authors explore the underlying ideological and cultural assumptions that exist within the posters and provide a method for evaluating such materials.

Babalola S. Readiness for HIV testing among young people in northern Nigeria: The roles of social norm and perceived stigma. AIDS Behav 2006 Dec 27; [Epub ahead of print].

Babalola examined the predictors of readiness for HIV testing among young people in northern Nigeria, paying special attention to the role of stigma. Stigma was measured at two levels: individual and community (social norm). There are commonalities and differences in the correlates of readiness for HIV testing among men and women. For men and women, knowledge about HIV prevention, knowledge about a source for VCT, discussion about condom use for HIV prevention and perceived risk are strong predictors. Knowledge that an apparently healthy person can be HIV-infected is only significant for women. Perceived stigma is a significant predictor for both men and women although the specific dimension of note differs between the sexes. Social norm is strongly and directly associated with readiness among men but has no apparent influence among women. For both sexes, social norm appears to have strong mediating influence on the relationship between personal perceived stigma and readiness. The author concludes that the results strongly suggest that to eliminate HIV-related stigma, it is not enough to target individual cognitive processes; strategic efforts should target social structures in order to change negative social norms.

Editors’ notes: Here is yet another study highlighting the importance of well designed social change communication strategies to create enabling environments for behavioural change and maintenance – in this case, the decision to take an HIV test.