Background: Antiretroviral therapy (ART) is a lifesaver for individual patients treated for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Maintaining optimal adherence to antiretroviral drugs is essential for HIV infection management. This study aimed to understand the factors influencing adherence amongst ART-prescribed patients and care providers in Nepal. Methods: A cross-sectional mixed-methods study surveying 330 ART-prescribed patients and 34 in-depth interviews with three different types of stakeholders: patients care providers and key people at policy level. Adherence was assessed through survey self-reporting and during the interviews. A multivariate logistic regression model was used to identify factors associated with adherence supplemented with a thematic analysis of the interview transcripts. Results: A total of 282 (85.5%) respondents reported complete adherence i.e. no missed doses in the four-weeks prior to interview. Major factors influencing adherence were: non-disclosure of HIV status (OR = 17.99 p = 0.014); alcohol use (OR = 12.89 p = 1 hour (OR = 2.84 p = 0.035). Similarly lack of knowledge and negative perception towards ART medications also significantly affected non-adherence. Transport costs (for repeat prescription) followed by pills running out not wanting others to notice side-effects and being busy were the most common reasons for non-adherence. The interviews also revealed religious or ritual obstacles stigma and discrimination ART-associated costs transport problems lack of support and side-effects as contributing to non-adherence. Conclusion: Improving adherence requires a supportive environment; accessible treatment; clear instructions about regimens; and regimens tailored to individual patients lifestyles. Healthcare workers should address some of the practical and cultural issues around ART medicine whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients.

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Factors Influencing Adherence to Antiretroviral Treatment in Nepal: A Mixed-Methods Study

The right not to know HIV-test results [letter]

Background : HIV/AIDS and Ebola Virus Disease (EVD) are contemporary epidemics associated with significant social stigma in which communities affected suffer from social rejection, violence, and diminished quality of life. Objective : To compare and contrast stigma related to HIV/AIDS and EVD, and strategically think how lessons learned from HIV stigma can be applied to the current EVD epidemic. Methods : To identify relevant articles about HIV/AIDS and EVD-related stigma, we conducted an extensive literature review using multiple search engines. PubMed was used to search for relevant peer-reviewed journal articles and Google for online sources. We also consulted the websites of the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and the National Institutes of Health to retrieve up-to-date information about EVD and HIV/AIDS. Results : Many stigmatizing attitudes and behaviors directed towards those with EVD are strikingly similar to those with HIV/AIDS but there are significant differences worthy of discussion. Both diseases are life-threatening and there is no medical cure. Additionally misinformation about affected groups and modes of transmission runs rampant. Unlike in persons with EVD, historically criminalized and marginalized populations carry a disproportionately higher risk for HIV infection. Moreover, mortality due to EVD occurs within a shorter time span as compared to HIV/AIDS. Conclusions : Stigma disrupts quality of life, whether it is associated with HIV infection or EVD. When addressing EVD, we must think beyond the immediate clinical therapeutic response, to possible HIV implications of serum treatment. There are emerging social concerns of stigma associated with EVD infection and double stigma associated with EVD and HIV infection. Drawing upon lessons learned from HIV, we must work to empower and mobilize prominent members of the community, those who recovered from the disease, and organizations working at the grassroots level to disseminate clear and accurate information about EVD transmission and prevention while promoting stigma reduction in the process. In the long run, education, prevention, and a therapeutic vaccine will be the optimal solutions for reducing the stigma associated with both EVD and HIV. Keywords : HIV; Ebola; stigma; healthcare (Published: 7 November 2014) Citation : Glob Health Action 2014,  7 : 26058 -  http://dx.doi.org/10.3402/gha.v7.26058

https://www.tandfonline.com/doi/pdf/10.3402/gha.v7.26058

Addressing Ebola-related stigma: lessons learned from HIV/AIDS.

We studied the impact of antiretroviral treatment availability on HIV/AIDS stigma through interviews with 118 antiretroviral treatment users, HIV/AIDS caregivers, and nurses in Zimbabwe. Treatment enables positive social and economic participation through which users can begin to reconstruct their shattered sense of social value. However, stigma remains strong, and antiretroviral treatment users remain mired in conflictual symbolic relationships between the HIV/AIDS people and the untested. To date, the restoration of users' own sense of self-worth through treatment has not reduced fear and sexual embarrassment in framing community responses to people living with HIV/AIDS. Much remains to be learned about the complex interaction of economic and psychosocial dimensions of poverty, treatment availability, and conservative sexual moralities in driving HIV/AIDS stigma in specific settings.

https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2010.202838

"We, the AIDS people. . .": how antiretroviral therapy enables Zimbabweans living with HIV/AIDS to cope with stigma

HIV and tuberculosis: the construction and management of double stigma.

The aim of this literature review is to elucidate what is known about HIV/AIDS and stigma in Sub-Saharan Africa. Literature about HIV/AIDS and stigma in Sub-Saharan Africa was systematically searched in Pubmed, Medscape, and Psycinfo up to March 31, 2009. No starting date limit was specified. The material was analyzed using Gilmore and Somerville's (1994) four processes of stigmatizing responses: the definition of the problem HIV/AIDS, identification of people living with HIV/AIDS (PLWHA), linking HIV/AIDS to immorality and other negative characteristics, and finally behavioural consequences of stigma (distancing, isolation, discrimination in care). It was found that the cultural construction of HIV/AIDS, based on beliefs about contamination, sexuality, and religion, plays a crucial role and contributes to the strength of distancing reactions and discrimination in society. Stigma prevents the delivery of effective social and medical care (including taking antiretroviral therapy) and also enhances the number of HIV infections. More qualitative studies on HIV/AIDS stigma including stigma in health care institutions in Sub-Saharan Africa are recommended.

https://downloads.hindawi.com/journals/jtm/2009/145891.pdf

Stigma of People with HIV/AIDS in Sub-Saharan Africa: A Literature Review

Although there are an increasing number of studies on HIV-related stigma in Nigeria, very little research has focused on how power differences based on gender perpetuate the stigmatization of people living with HIV/AIDS (PLWHA) and how these gender differences affect the care that PLWHA receive in health care institutions. We explore gender-related beliefs and reactions of society, including health care professionals (HCPs), with regard to PLWHA, using Connell's theoretical framework of gender and power (1987). With Connell's structural theory of gender and power (financial inequality, authority and structure of social norms), we can describe gender differences in stigmatization of PLWHA. We conducted in-depth semi-structured interviews, lasting 60 to 90 minutes, with 100 persons (40 members of the general public, 40 HCPs and 20 PLWHA) in Port Harcourt, Nigeria. The interviews were tape-recorded and transcribed verbatim. The Nvivo 7 computer package was used to analyze the data. There are similarities and differences between the general public and HCPs towards PLWHA in gender-related beliefs and reactions. For instance, although association with promiscuity and power differences were commonly acknowledged in the different groups, there are differences in how these reactions are shown; such as HCPs asking the female PLWHA to inform their partners to ensure payment of hospital bills. Women with HIV/AIDS in particular are therefore in a disadvantaged position with regard to the care they receive. Despite the fact that men and women with HIV/AIDS suffer the same illness, clear disparities are apparent in the negative reaction women and men living with HIV/AIDS experience in society. We show that women's generally low status in society contributes to the extreme negative reactions to which female PLWHA are subject. The government should create policies aimed at reducing the power differences in family, society and health care systems, which would be important to decrease the gender-related differences in stigma experienced by PLWHA. Interventions should be directed at the prevailing societal norms through appropriate legislation and advocacy at grassroots level with the support of men to counter laws that put women in a disadvantaged position. Furthermore, development of a policy that encourages equality in access to health care for all patients with HIV/AIDS by applying the same conditions to both men and women in health care institutions is recommended. There is a need to protect women's rights through implementing support policies, including paying attention to gender in the training of HCPs.

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Gender-related power differences, beliefs and reactions towards people living with HIV/AIDS: an urban study in Nigeria

People living with HIV or AIDS (PLHIV) in sub-Saharan Africa sometimes have care-seeking behaviours that result in a suboptimal quality of life. This paper seeks to examine the role of stigma in the care-seeking behaviour of PLHIV. We hypothesise that stigma relates to the behaviour of PLHIV themselves and with societal reactions, including those of healthcare professionals. From a literature review, we identified the following as important correlates of care-seeking behavior: beliefs about pathways of HIV infection and people infected with HIV, social reactions, coping strategies, knowledge of HIV and AIDS, and self-efficacy in finding care and treatment in addition to coping with the disease. Poverty, gender, age, religion and policy were found to be moderating variables. The Precede-Proceed model was adapted to build an explanatory model of healthcare-seeking behaviour among PLHIV and particularly to explore the role of stigma in the non-utilisation of healthcare institutions.

A model for understanding the relationship between stigma and healthcare-seeking behaviour among people living with HIV/AIDS in sub-Saharan Africa.

In 2009, approximately 2.98 million people in Nigeria were living with HIV/AIDS. More than 192,000 deaths were caused by AIDS and 2.175 million AIDS orphans are now living in Nigeria (UNAIDS, 2010). The availability of anti-retroviral therapy (ART) implies that people living with HIV/AIDS (PLWHA) should be able to carry out daily activities like the rest of society. However, there are a number of hindrances to the utilization of care, leading to suboptimal effectiveness of available treatment (Hilhorst et al., 2006; Morolake et al., 2009). One of the factors seems to be stigma; PLWHA and their care givers have to cope with negative reactions from the people directly around them as well as from the community (Mwinituo & Mill, 2006; Mitchell et al., 2007; Sabin et al., 2008; Adewuya et al., 2009; Hejoaka, 2009; Demmer, 2011). A study carried out among home based care givers in KwaZulu Natal South Africa showed that home based care givers experience high levels of burden and are targets of HIV-related prejudice and discrimination (Singh et al., 2011). Not only does the discovery that one is infected with HIV lead to fear of progression into AIDS and fear of dying, it also creates an anticipation of negative social reactions among PLWHA. Sontag (1989) argues that it is not the suffering of the disease that is deeply feared, but the denigration that is suffered from having the disease that makes PLWHA vulnerable as individuals and within society. People in the community have a negative attitude towards PLWHA because they attribute the characteristic of promiscuity to those who are infected (Campbell et al., 2007). Societal norms and values in Nigeria are restrictive and secretive, while discussion about sex is often private for cultural and religious reasons (Ajuwon et al., 1998), making people who transgress these norms likely to be condemned because norms are very strong and strict. Several studies around the world (Amirkhanian et al., 2003; Singh et al., 2009; Stevelink et al., 2011; Vlassoff & Ali, 2011) and in Africa indicate that PLWHA are still discriminated against (Muyinda et al., 1997; Duffy, 2005; Shisana et al., 2005; Muula & Mfutso-Bengo, 2005; Hilhorst et al., 2006; Liamputtong et al., 2009; Morolake et al., 2009; Amuri et al., 2011), making them resort to varied ways of coping with their problems (Mbonu et al., 2009). Despite these studies indicating the presence of stigma, literature have equally acknowledged that one of the positive noticeable interventions in the fight of HIV/AIDS

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The Experiences and Complexities of Care-Seeking Behavior of People Living with HIV/AIDS: A Qualitative Study in Nigeria

Although the overall growth of the global AIDS epidemic appears to have stabilized, still, Sub-Saharan Africa has the majority of new infections with 1.8 million (1.6 million2.0 million) people becoming infected in 2009 (UNAIDS, 2010). Sub-Saharan Africa remains the region most heavily affected by HIV/AIDS, accounting for 68% of all people living with HIV/AIDS (PLWHA) and for 72% of AIDS related deaths in 2009 (UNAIDS, 2010). In West Africa, Nigeria has the largest epidemic in absolute numbers (UNAIDS, 2008) with 2.98 million people living with HIV and 192,000 adults and child deaths from AIDS in 2009 (UNAIDS, 2010). The HIV/AIDS prevalence rate in Nigeria remains uneven across different states (Utulu & Lawoyin, 2007; UNAIDS, 2010). A retrospective study carried out between 2000 and 2004 among 10,032 pregnant women attending the antenatal clinic at the Braithwaite Memorial Hospital, Port Harcourt Nigeria showed that 5.93% of the women were HIVpositive patients (Obi et al., 2007). Another study carried out in the university teaching hospital at Port Harcourt Nigeria between 1999 and 2004 showed a paediatric prevalence rate of 25.8% (Alikor & Erhabor, 2005). More recently, HIV prevalence among pregnant women attending antenatal clinic in Rivers State is 7.3% in 2008 (UNAIDS, 2010) making Rivers state one of the states with high HIVprevalence among pregnant women in Nigeria. One of the many challenges associated with HIV/AIDS is stigma. Stigma is generally recognized as an ‘attribute that is deeply discrediting’ that reduces the bearer ‘from a whole and usual person to a tainted, discounted one’ (Goffman, 1974). Herek (2002) describes stigma as an enduring condition, status, or attribute that is negatively valued by a society and whose possession consequently discredits and disadvantages an individual (Herek, 2002). Steward and colleagues noted further that stigma is very much about the socially constructed meanings associated with the attribute or characteristic (Steward et al., 2008). Because AIDS or HIV infection is an enduring condition or characteristic that is negatively valued (Herek, 2002), AIDS-related stigma continues to be a barrier to caring for, and supporting, people whose HIV status is known in society (Campbell et al., 2007). Stigma arises and stigmatization takes shape in specific contexts of culture and power (Parker & Aggleton, 2003). Stigma is especially significant in many developing countries, such as those in Africa, where social networks and, therefore, societal values, are relatively

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Ngozi C. Mbonu

Papers

Stigma of People with HIV/AIDS in Sub-Saharan Africa: A Literature Review

Gender-related power differences, beliefs and reactions towards people living with HIV/AIDS: an urban study in Nigeria

A model for understanding the relationship between stigma and healthcare-seeking behaviour among people living with HIV/AIDS in sub-Saharan Africa.

The Experiences and Complexities of Care-Seeking Behavior of People Living with HIV/AIDS: A Qualitative Study in Nigeria

Societal Beliefs and Reactions About People Living with HIV/AIDS