Effect of stigma reduction intervention strategies on HIV test uptake in low- and middle-income countries: a realist review protocol

Background Several stigma reduction intervention strategies have been developed and tested for effectiveness in terms of increasing human immunodeficiency virus (HIV) test uptake. These strategies have been more effective in some contexts and less effective in others. Individual factors, such as lack of knowledge and fear of disclosure, and social-contextual factors, such as poverty and illiteracy, might influence the effect of stigma reduction intervention strategies on HIV test uptake in low- and middle-income countries. So far, it is not clearly known how the stigma reduction intervention strategies interact with these contextual factors to increase HIV test uptake. Therefore, we will conduct a review that will synthesize existing studies on stigma reduction intervention strategies to increase HIV test uptake to better understand the mechanisms underlying this process in low- and middle-income countries. Methods A realist review will be conducted to unpack context-mechanism-outcome configurations of the effect of stigma reduction intervention strategies on HIV test uptake. Based on a scoping review, we developed a preliminary theoretical framework outlining a potential mechanism of how the intervention strategies influence HIV test uptake. Our realist synthesis will be used to refine the preliminary theoretical framework to better reflect mechanisms that are supported by existing evidence. Journal articles and grey literature will be searched following a purposeful sampling strategy. Data will be extracted and tested against the preliminary theoretical framework. Data synthesis and analysis will be performed in five steps: organizing extracted data into evidence tables, theming, formulating chains of inference from the identified themes, linking the chains of inference and developing generative mechanisms, and refining the framework. Discussion This will be the first realist review that offers both a quantitative and a qualitative exploration of the available evidence to develop and propose a theoretical framework that explains why and how HIV stigma reduction intervention strategies influence HIV test uptake in low- and middle-income countries. Our theoretical framework is meant to provide guidance to program managers on identifying the most effective stigma reduction intervention strategies to increase HIV test uptake. We also include advice on how to effectively implement these strategies to reduce the rate of HIV transmission.status: publishe

The Impact of the SEERs Project on HIV Testing in Kenya

Compared to other key populations, adolescents living in sub-Saharan Africa experience a high HIV disease burden. To address this, organizations have implemented a variety of youth-oriented HIV prevention strategies, including the HIV SEERs Project. SEERs is an innovative, community-based program designed with and for youth in Kenya to reduce HIV stigma (a known barrier to HIV testing), and increase treatment and retention in care. While preliminary research has demonstrated SEERs efficacy for increasing HIV knowledge and decreasing stigma, information about its efficacy as a means to increase HIV testing has been limited to assessing behavioral intentions. To address this limitation, SEERs facilitators partnered with 20 local HIV agencies in 2018 to offer on-site HIV testing during SEERs programming. The purpose of this article is to examine the impact, as well as the benefits and challenges of SEERs programming on HIV testing and linkage to care. SEERs facilitators collected and reported the following data monthly over the course of the year: number of locations for SEERs programming, number and age range of SEERs attendees, number of attendees who screened for HIV and, among those, the number who tested positive and were linked to care. Facilitators also provided written descriptions of the benefits and challenges of implementing the SEERs programming. We analyzed HIV testing data using descriptive statistics and used qualitative data to describe facilitators’ perceptions of the benefits and challenges of implementing the SEERs program. We discuss the contributions of these findings to the existing literature and explore future directions

HIV in the leather community: Rates and risk-related behaviors

There exist many subcultures of men who have sex with men (MSM), all with differing values and health behaviors. The Leathermen comprise one such subculture, which is characterized by a heightened valuation of hypersexuality and adherence to sexual control dynamics (i.e., submission and dominance). No previous research has specifically examined this community for differences in sexual health (e.g., HIV rates) and sexual health behaviors (e.g., condom use). We conducted a large survey of men (N = 1,554) at one leather and non-leather event, collecting data from 655 Submissives, Dominants, Switches, and non-orienting Leathermen. Leathermen were 61% more likely to be HIV-positive than non-Leathermen. Decreased condom use found in HIV-positive Leathermen (relative to HIV-positive non-Leathermen) was a potential factor contributing to heightened HIV rates. Universal low condom use in Submissives engaging in receptive, and Dominants engaging in insertive, anal intercourse was an additional trend that potentially contributed to increased numbers of HIV-positive Leathermen. Our recommendation is for heightened awareness of the risks associated with sex among Leathermen, especially unprotected anal intercourse with sero-uncertain Submissives. © 2009 Springer Science+Business Media, LLC

"Just like fever": a qualitative study on the impact of antiretroviral provision on the normalisation of HIV in rural Tanzania and its implications for prevention.

BACKGROUND: Once effective therapy for a previously untreatable condition is made available, a normalisation of the disease often occurs. As part of a broader initiative to monitor the implementation of the national antiretroviral therapy (ART) programme, this qualitative study investigated the impact of ART availability on perceptions of HIV in a rural ward of North Tanzania and its implications for prevention. METHODS: A mix of qualitative methods was used including semi-structured interviews with 53 ART clinic clients and service providers. Four group activities were conducted with persons living with HIV. Data were analyzed using the qualitative software package NVIVO-7. RESULTS: People on ART often reported feeling increasingly comfortable with their status reflecting a certain "normalization" of the disease. This was attributed to seeing other people affected by HIV, regaining physical health, returning to productive activities and receiving emotional support from health service providers. Overcoming internalized feelings of shame facilitated disclosure of HIV status, helped to sustain treatment, and stimulated VCT uptake. However "blaming" stigma - where people living with HIV were considered responsible for acquiring a "moral disease" - persisted in the community and anticipating it was a key barrier to disclosure and VCT uptake. Attributing HIV symptoms to witchcraft seemed an effective mechanism to transfer "blame" from the family unit to an external force but could lead to treatment interruption. CONCLUSION: As long as an HIV diagnosis continues to have moral connotations, a de-stigmatisation of HIV paralleling that occurring with diseases like cancer is unlikely to occur. Maximizing synergies between HIV treatment and prevention requires an enabling environment for HIV status disclosure, treatment continuation, and safer sexual behaviours. Local leaders should be informed and sensitised and communities mobilised to address the blame-dimension of HIV stigma