Stigma, Health Care Access, and HIV Knowledge Among Men Who Have Sex With Men in Malawi, Namibia, and Botswana
TL;DR: Strong associations were observed between experiences of discrimination and fear of seeking health care services, and HIV knowledge among men who have sex with men in Malawi, Namibia, and Botswana.
Abstract: Same-sex practices are stigmatized in much of sub-Saharan Africa. Cross-sectional relationships between discrimination, access to and use of health care services, and HIV knowledge among men who have sex with men (MSM) were assessed in Malawi, Namibia, and Botswana. A survey and HIV screening were used to explore these variables and the prevalence of HIV. Overall, 19% of men screened positive for HIV infection. Ninety-three percent knew HIV is transmitted through anal sex with men, however, only 67% had ever received information of how to prevent this transmission. Few (17%) reported ever disclosing same sex practices to a health professional and 19% reported ever being afraid to seek health care. Men reported ever been denied health care services (5%) and 21% had ever been blackmailed because of their sexuality. Strong associations were observed between experiences of discrimination and fear of seeking health care services. Characterizing the relationship between stigma and health care seeking practices and attitudes can inform the development and implementation of HIV interventions for African MSM.
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TL;DR: It is shown that the high probability of transmission per act through receptive anal intercourse has a central role in explaining the disproportionate disease burden in MSM and prevention strategies that lower biological transmission and acquisition risks offer promise.
1,369 citations
TL;DR: The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response.
Abstract: Introduction : HIV-related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response. Methods : We conducted a systematic review of studies and reports that assessed the effectiveness of interventions to reduce HIV stigma and discrimination between 1 January 2002 and 1 March 2013. Databases searched for peer-reviewed articles included PubMed, Scopus, EBSCO Host -CINAHL Plus, Psycinfo, Ovid, Sociofile and Popline. Reports were obtained from the www.HIVAIDSClearinghouse.eu , USAID Development Experience Clearinghouse, UNESCO HIV and AIDS Education Clearinghouse, Google, WHO and UNAIDS. Ancestry searches for articles included in the systematic review were also conducted. Studies of any design that sought to reduce stigma as a primary or secondary objective and included pre- and post-intervention measures of stigma were included. Results : Of 2368 peer-reviewed articles and reports identified, 48 were included in our review representing 14 different target populations in 28 countries. The majority of interventions utilized two or more strategies to reduce stigma and discrimination, and ten included structural or biomedical components. However, most interventions targeted a single socio-ecological level and a single domain of stigma. Outcome measures lacked uniformity and validity, making both interpretation and comparison of study results difficult. While the majority of studies were effective at reducing the aspects of stigma they measured, none assessed the influence of stigma or discrimination reduction on HIV-related health outcomes. Conclusions : Our review revealed considerable progress in the stigma-reduction field. However, critical challenges and gaps remain which are impeding the identification of effective stigma-reduction strategies that can be implemented by national governments on a larger scale. The development, validation, and consistent use of globally relevant scales of stigma and discrimination are a critical next step for advancing the field of research in this area. Studies comparing the effectiveness of different stigma-reduction strategies and studies assessing the influence of stigma reduction on key behavioural and biomedical outcomes are also needed to maximize biomedical prevention efforts. Keywords : systematic review; HIV; stigma reduction; discrimination reduction; interventions; measurement. (Published: 13 November 2013) To access the supplementary material to this article please see Supplementary Files in the column to the right (under Article Tools). Citation : Stangl AL et al. Journal of the International AIDS Society 2013, 16 (Suppl 2):18734 http://www.jiasociety.org/index.php/jias/article/view/18734 | http://dx.doi.org/10.7448/IAS.16.3.18734
529 citations
TL;DR: This Series paper raises the parallel question of whether discrimination based on gender likewise becomes embodied, with negative consequences for health, as well as how gender-biased health research and health-care systems reinforce and reproduce gender inequalities, with serious implications for health.
417 citations
TL;DR: Modelling suggests that, with sufficient coverage, available interventions are sufficient to avert at least a quarter of new HIV infections in MSM in diverse countries.
374 citations
TL;DR: Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.
Abstract: Epidemics of HIV in MSM continue to expand in most low, middle, and upper income countries in 2013 and rates of new infection have been consistently high among young MSM. Current prevention and treatment strategies are insufficient for this next wave of HIV spread. We conducted a series of comprehensive reviews of HIV prevalence and incidence, risks for HIV, prevention and care, stigma and discrimination, and policy and advocacy options. The high per act transmission probability of receptive anal intercourse, sex role versatility among MSM, network level effects, and social and structural determinants play central roles in disproportionate disease burdens. HIV can be transmitted through large MSM networks at great speed. Molecular epidemiologic data show marked clustering of HIV in MSM networks, and high proportions of infections due to transmission from recent infections. Prevention strategies that lower biological risks, including those using antiretrovirals, offer promise for epidemic control, but are limited by structural factors including, discrimination, criminalization, and barriers to healthcare. Subepidemics, including among racial and ethnic minority MSM in the United States and UK, are particularly severe and will require culturally tailored efforts. For the promise of new and combined bio-behavioral interventions to be realized, clinically competent healthcare is necessary and community leadership, engagement, and empowerment are likely to be key. Addressing the expanding epidemics of HIV in MSM will require continued research, increased resources, political will, policy change, structural reform, community engagement, and strategic planning and programming, but it can and must be done.
289 citations
Cites background from "Stigma, Health Care Access, and HIV..."
...Studies of MSM clients have shown that stigma limits uptake of HIV services [26,49,50]....
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...Individual level biological and behavioral risks among these populations are likely contextualized by higher order risk factors including size and density of social and sexual networks, and stigma [26,49,50]....
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...Stigma targeting MSM has been shown to limit both the provision and uptake of HIV services [50]....
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References
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TL;DR: In this article, the authors discuss the relationship between information control and personal identity, including the Discredited and the Discreditable Social Information Visibility Personal Identity Biography Biographical Others Passing Techniques of Information Control Covering.
Abstract: CONTENTS 1. Stigma and Social Identity Preliminary Conceptions The Own and the Wise Moral Career 2. Information Control and Personal Identity The Discredited and the Discreditable Social Information Visibility Personal Identity Biography Biographical Others Passing Techniques of Information Control Covering 3. Group Alignment and Ego Identity Ambivalence Professional Presentations In-Group Alignments Out-Group Alignments The Politics of Identity 4. The Self and Its Other Deviations and Norms The Normal Deviant Stigma and Reality 5. Deviations and Deviance
17,631 citations
Book•
01 Jan 1963
TL;DR: In this article, the authors discuss the relationship between information control and personal identity, including the Discredited and the Discreditable Social Information Visibility Personal Identity Biography Biographical Others Passing Techniques of Information Control Covering.
Abstract: CONTENTS 1. Stigma and Social Identity Preliminary Conceptions The Own and the Wise Moral Career 2. Information Control and Personal Identity The Discredited and the Discreditable Social Information Visibility Personal Identity Biography Biographical Others Passing Techniques of Information Control Covering 3. Group Alignment and Ego Identity Ambivalence Professional Presentations In-Group Alignments Out-Group Alignments The Politics of Identity 4. The Self and Its Other Deviations and Norms The Normal Deviant Stigma and Reality 5. Deviations and Deviance
13,742 citations
TL;DR: The nature and extent of stigma in a group of individuals with epilepsy in remission is described, and the distinction between 'felt' and 'enacted' stigma is examined, and found to be supported by the data.
576 citations
"Stigma, Health Care Access, and HIV..." refers background in this paper
...Internalized stigma, or for gay men and other MSM internalized homophobia, refers to how an individual feels about his sexuality and can include feelings of shame and fear, which often relate to experienced stigma [7]....
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TL;DR: 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, and interventions are needed to reduce perceived stigma in the health care setting.
Abstract: 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/AIDS (PLWHAs). 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...
360 citations
"Stigma, Health Care Access, and HIV..." refers background in this paper
...Poor access to care can lead to an underutilization of services, such as HIV voluntary counseling and testing, and ultimately to low self-awareness of HIV serostatus [1, 17]....
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...Infection with HIV or being identified as a person at high risk for HIV still carries a stigma, as infected and high risk individuals are often associated with behaviors shunned by society, including same sex practices [1, 2]....
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TL;DR: MSM are a high-risk group for HIV infection and human rights abuses in Malawi, Namibia, and Botswana and these countries should initiate and adequately fund evidence-based and targeted HIV prevention programs for MSM.
Abstract: Background
In the generalized epidemics of HIV in southern Sub-Saharan Africa, men who have sex with men have been largely excluded from HIV surveillance and research. Epidemiologic data for MSM in southern Africa are among the sparsest globally, and HIV risk among these men has yet to be characterized in the majority of countries.
Methodology
A cross-sectional anonymous probe of 537 men recruited with non-probability sampling among men who reported ever having had sex with another man in Malawi, Namibia, and Botswana using a structured survey instrument and HIV screening with the OraQuick© rapid test kit.
Principal Findings
The HIV prevalence among those between the ages of 18 and 23 was 8.3% (20/241); 20.0% (42/210) among those 24–29; and 35.7% (30/84) among those older than 30 for an overall prevalence of 17.4% (95% CI 14.4–20.8). In multivariate logistic regressions, being older than 25 (aOR 4.0, 95% CI 2.0–8.0), and not always wearing condoms during sex (aOR 2.6, 95% CI 1.3–4.9) were significantly associated with being HIV-positive. Sexual concurrency was common with 16.6% having ongoing concurrent stable relationships with a man and a woman and 53.7% had both male and female sexual partners in proceeding 6 months. Unprotected anal intercourse was common and the use of petroleum-based lubricants was also common when using condoms. Human rights abuses, including blackmail and denial of housing and health care was prevalent with 42.1% (222/527) reporting at least one abuse.
Conclusions
MSM are a high-risk group for HIV infection and human rights abuses in Malawi, Namibia, and Botswana. Concurrency of sexual partnerships with partners of both genders may play important roles in HIV spread in these populations. Further epidemiologic and evaluative research is needed to assess the contribution of MSM to southern Africa's HIV epidemics and how best to mitigate this. These countries should initiate and adequately fund evidence-based and targeted HIV prevention programs for MSM.
347 citations
"Stigma, Health Care Access, and HIV..." refers background or methods in this paper
...The methods used in this study have been reported elsewhere [8]....
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...Same-sex practices are criminalized in all three countries, and currently no government funding is allocated to prevention programs for MSM in any of them [8]....
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...As of 2007, an estimated 200,000 people were living with HIV in Namibia, 300,000 in Botswana, and 930,000 in Malawi [8]....
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...Other demographic and behavioral characteristics, including sexual concurrency, current relationship, numbers of partners, and condom use in these study sites have been reported elsewhere [8]....
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...Among participants enrolled in an exploratory study among MSM in Malawi, 30% reported fear of discrimination and stigma if they were to disclose their sexuality to others, despite that the majority of participants felt comfortable with their sexual orientation [13], and Baral and colleagues reported that only 9% had ever disclosed to a health care worker [8]....
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